Claims Audits and Health Care Cost Containment

The coronavirus pandemic significantly increased medical expenses and highlighted the importance of healthcare audit services. These services provide an efficient means to scrutinize claim payments for any discrepancies. During the pandemic, many shocking instances of excessive charges came to light. It became crucial to promptly identify these issues, recover funds, and prevent similar occurrences. Effective oversight has proven beneficial, leading many employer-funded health plans to implement continuous monitoring of their claim payments. Nothing replaces accurate, real-time data.

This approach is an excellent tool for managing plans and can enhance services for members. Key advancements have significantly increased the value of claim auditing. The shift from random sampling to comprehensive 100 percent claim reviews has transformed the field. Audit firms have continually refined their proprietary software and methodologies, mainly due to these technological improvements, resulting in unmatched accuracy. The setup of audits is tailored to specific plan provisions, making it essential to choose a firm that customizes its approach to your needs.

Today, only a handful of professionals remember the era of random sampling, which now seems outdated. If you're an in-house manager of an employer-funded medical plan, collaborating with auditors specializing in claim reviews can be highly beneficial. These auditors can identify potential cost-saving opportunities due to their daily engagement in the industry and awareness of common errors and overpayment trends. You can implement valuable improvements by seeking their expertise and reviewing your plan. Claim administrators work more carefully when they know there is oversight.

Establishing a relationship with the same claim auditor for ongoing monitoring or periodic reviews can further enhance outcomes. As a firm becomes familiar with your plan, its ability to detect overpayments and recovery prospects improves. Upper management will likely appreciate the benefits of claim audits, which often yield recoveries that exceed the cost of the services. Additionally, the detailed reports provide an independent analysis of cost trends, reducing reliance on data from third-party processors and pharmacy benefit managers. It's an exercise in keeping them honest.