When large corporate or nonprofit employers sponsor their employee benefits, they put millions of dollars on the line. Healthcare plans are among the most expensive, and it’s why medical claims auditing and pharmacy claim reviews matter so much. There is a fiduciary responsibility to pay claims accurately, and with outside firms handling it, auditing is the most effective way to conduct oversight. It provides an objective third-party review of all payments and their accuracy, or not. Given the many factors affecting plans today, it’s easy to see why beefing up oversight is imperative.
When you’re working on plans and budgets for medical and pharmacy plans, claim audit reports are insightful. Compared to self-reporting from administrators, they complete the picture and provide independent confirmation. Today’s sophisticated audit software can answer most questions you can pose about plan performance. It can also find opportunities for savings and serving plan members better. You can quickly see why plan sponsors audit their claims more frequently and double-check their payments monthly. Auditors can run their systems unobtrusively in the background continuously.
Pre-audit planning allows you to have an information exchange with your audit firm. You can bring up areas of concern and listen to their suggestions about places of interest based on experience and past work. Electronic claim reviews today are more sophisticated than ever and powered by advanced systems that quickly bring the audit to the finish line. They also render easier-to-read (and understand) reports that give clear insights into the findings and analysis. Having factual performance data for meetings and negotiations with your claim administrator also informs that process.
If you audit claims only when required for regulatory compliance, you’re missing opportunities and may work farther in arrears than is optimal. Timely reviews that flag errors and irregularities shortly after they have occurred can facilitate easier recoveries if there are overpayments. Finding repeating mistakes earlier also means correcting systems and more easily avoiding million-dollar problems later. It adds value if you’re looking at auditing from a compliance, cost containment, fiduciary best practices, or member service standpoint. Double-checking claims always returns more money than the service’s price.