The firms specializing in claim audits have become increasingly (and impressively) more accurate. Request new proposals for your subsequent medical claim audits if you've been trusting this vital function to a firm with less expertise. You'll see better results when they're run on highly sophisticated systems and managed by executives with large health plan experience. Budget-friendly claim audits have become a plan management mainstay for large employers self-funding their benefit plans, both corporate and nonprofit. Your plan's provisions and standards are unique, and the audit setup needs to reflect them.
Most claim processing today is outsourced to large health insurance carriers. It makes sense because they have sophisticated systems and negotiated rates with providers. But it's easy for your claims to be paid on their system according only to their standards and provisions and overlooking aspects of yours. It may go in your favor financially, and in other cases, it may not. A detailed audit will sort through the particulars and help ensure you get the best value in every situation. It should be noted that today's claim audits can electronically review 100 percent of payments.
All audits are detail-oriented, but medical claims are two-dimensional. There are standard financial points to check, but there are also utilization issues. When generalist firms run a tax audit, they only check the numbers. With medical and pharmacy claims, there are many other factors. Depending on your plan and its payments, duplicate tests and services, discounts and preferred rates, and non-covered expenses are all examples of things claim audits might catch. It's wise to audit routinely if you aren't already doing so and consider monitoring continuously. It can run on the same auditor's software.
Implementation audits are another beneficial move when switching your claim processing to a new third-party administrator or pharmacy benefit manager. Despite everyone's best efforts and intentions, it's common for things to be overlooked. When your plan is flawlessly set up on the new system, and your special provisions are added, you'll see an improvement in claim payment accuracy automatically. Then you'll achieve the planned cost savings with no additional effort, and the system will be in place to continue the trends into the future. Claim auditing early and often makes sense for all health plans.