The one thing that’s certain about medical and pharmacy claims is that they increase in price yearly. That’s why scheduling a healthcare audit routinely is such a wise idea. It easily falls under the fiduciary best practices umbrella and is a plan management benefit. Thanks to advanced software and systems, electronic claim reviews can check each claim for thousands of provisions and report actionable data. When those powerful and often proprietary systems double-check hundreds of thousands of claims daily, they can flag hundreds of irregularities. It’s the quickest way to find mistakes and overpayments.
Because the costs and numbers are high for medical and pharmacy claims, it’s become standard to audit them routinely, if not monthly. Specialist auditors can easily prove the exceptional value of their service by demonstrating that recoveries exceed their fees – routinely by as much as four times. The COVID-19 pandemic clarified what can happen when unexpected and extraordinary events occur. Utilization spiked, and new tests and treatments suddenly came onto the market. Urgent medical situations and the rush to treat the sick meant the healthcare system had little time to set and agree to their pricing.
Health care claim auditing was thrust into the spotlight as large employer-sponsored medical plans were with extraordinary cost increases. Taking an analytical look meant dissecting each claim paid and seeing if there were charges to question. Thanks to the efficiency of today’s claim reviews, very little falls through the cracks and escapes examination. It also informally plays a “keeping them honest” role with providers when they know large plans are reviewing payments. It’s a level of oversight that goes beyond what claim administrators conduct when making the payments, creating a two-layered system.
Looking back in history, only a few years, you’ll see that random sample audits to meet regulatory requirements were most of what was happening. They played some role in controlling costs but provided nowhere near the level of review feasible today. When electronic claim reviews handle the lion’s share of the process and reduce human time commitment, there are efficiency gains. The entire equation revolves around delivering the proper care at the most reasonable price attainable. Therefore, it’s clear why claim auditing for health and pharmacy plans is increasingly popular.
