Most medical plan sponsors understand the value of   healthcare audit services   in terms of cost savings and improved member service. It's also reasonable to recognize that continuous monitoring using the same audit software offers similar potential benefits. With claims processing typically outsourced, conducting audits is the best defense against costly errors and overpayments. While TPAs and PBMs often make performance guarantees, relying on them to self-report without independent review carries obvious risks. Therefore, it's advisable to have a claim auditor doublecheck their work. 

The game-changer in claim auditing accuracy has been the 100-percent method made possible by technological advances. Software improvements now enable quick review of all claims against hundreds, if not thousands, of checkpoints, resulting in data of unparalleled accuracy. These tools empower in-house staff to oversee claim administrators more effectively than ever before, allowing them to monitor performance guarantees and address expense trends in their early stages. Medical plans that undergo frequent audits or continuous monitoring have reported better management outcomes. 

Real-time expense monitoring is crucial, given the significant impact that spikes in claim costs can have on balance sheets. Continuous monitoring services run audit software in the background at all times, providing monthly reports. The value of the mistakes it flags exceeds the cost of the service, making it budget-friendly. Upper management appreciates the data provided, as it allows them to explain costs to financial analysts and others more effectively. Engaging an independent claim audit firm specializing in the field and using proprietary software and methods to deliver high-quality results is essential. 

After all, auditing is only as good as the data it generates. If you've been conducting audits solely to meet regulatory requirements, consider increasing the frequency of audits for both medical and pharmacy claims, at least annually. The sponsors of the best-managed plans view audits as their most effective means of management and oversight. Neglecting audits for too long can lead to a pile-up of mistakes and overpayments that are challenging to recover. Working in arrears often creates issues you don't face when working closer to real-time. It also helps keep budget overages more in check.

Keeping employee benefit plans running well is imperative for companies that self-fund them. It's the same for large nonprofit employers with similar benefit setups. Led by medical claim auditing , reviewing all benefit plan payments is imperative. Oversight is crucial because claim administrators make the payments and, therefore, have control of your company's checkbook. Outsourced processors are generally large health plans with sophisticated infrastructure. But they're set up to process claims in their own way, and your plan may have unique provisions. Auditors help you see that your rules are followed.

An opportunity exists if you've had variations in expenses and budgets outside the expected parameters and are only auditing periodically as required for compliance. When you begin to audit more often (and more thoroughly), you'll have details and explanations for the cost variances. Your outsourced claim administrator will self-report, but the independent audit review confirms their accuracy. With the dollar amounts on the line in medical and pharmacy claims, keeping an eye on payments and any irregularities is imperative. The most challenging thing is waiting until you have a million-dollar problem.

C-suite executives who are called on to discuss quarterly earnings reports need backup and detail when there are expense variations. Given the cost exposures of medical and pharmacy plans for large employee groups, it's essential to have factual data. It's another reason to audit claim payments routinely and use a responsive audit firm that produces thorough reports. Given today's systems, you can pose any question about your payments for scrutiny, and auditors can deliver answers. It's extraordinarily helpful insight and oversight when you have an outsourced claims administrator.

It's also trending to have your claims audited continuously with frequent reports to keep watch on every detail. Even small things add to significant sums, given the price of medical services and medicines. There is no substitute for oversight and management, and when you're detached from the process and using a third party, running an independent review is the best way to double-check. Every plan benefits from closer management, and members are served better when payments are accurate. You may begin frequent auditing with cost containment support in mind, but you'll find it has many benefits in the long run.

It’s a meaningful event when large employer-funded benefit plans change claim administrators. Since medical and pharmacy claims are the most significant expenses,  healthcare auditing companies .  should be involved. Implementation auditing is one of the most significant opportunities to catch preliminary errors and get things off on the right foot. Even the most advanced processing systems can make errors, and detecting them quickly pays off. If your plan needs to request overpayment recovery, doing it shortly after the fact is always smoother. Working several months in arrears is always more challenging.

Today’s claim processing systems are built to be accurate, but things change rapidly, and not every setup can always be correct. Claim auditors who can detect errors quickly always add value, and today, they commonly review every claim – it’s a leap ahead from the days when it was about random sample audits that were generalizations without pinpoint accuracy. Now, you can “slice and dice” claim payments in many ways electronically, reviewing them for many factors. Given the complexity of each claim, it’s beneficial to have the ability. Medical coding is also a complex endeavor that creates complications.

The most effective healthcare claims auditing combines knowledge of advanced audit techniques with medical (and pharmacy) billing knowledge. The opportunities to find irregularities are significant when reviewing thousands of claims. The percentages may be low and make administrators appear effective, but the dollar amounts can be substantial when every incorrect claim is flagged. It also holds that the only way to know your processing setup is correct is to audit claims about three months after implementation. Conducting oversight of processors is a beneficial part of plan management.

Protecting your audit rights is crucial when negotiating an agreement with a new claim processor. Some may try to substitute self-reporting for an independent claim review or limit your rights in some instances. As a plan sponsor, the right should be yours because the plan is yours, and it’s your company or nonprofit’s money paying the claims. After the implementation phase, audit frequency is up to you, and you may elect to have the audit software run continuously. If you have monthly reports with factual data at your fingertips, you’re in a much stronger position to manage your plan proactively.