The work of medical claim auditors has evolved significantly for large corporate and nonprofit employers managing benefit plans. While random sample audits were the norm in the past, today, medical claim auditors review 100% of payments with remarkable speed and precision. This meticulous process involves testing the accuracy of all payments against the plan’s covered services and price agreements, enabling auditors to identify overpayments, errors, and irregularities in great detail. The data obtained from these audits provides excellent oversight of third-party claim administrators handling payments.
It’s interesting to note that what started as a regulatory requirement has now become a crucial management function that saves large plans substantial amounts of money annually, often reaching into the millions. Technological advancements and specialized firms have played a significant role in enhancing the accuracy and efficiency of claim audits. While there are generalist audit companies that review claim payments, the expertise of full-time claim auditors, especially those with experience in managing large health plans, remains unparalleled. They are in the trenches daily, gaining knowledge.
Despite the guarantees of accuracy and performance made by third-party administrators (TPAs) and pharmacy benefit managers (PBMs), only an independent audit can truly confirm their claims. Relying on administrators to self-regulate falls short of providing conscientious oversight, making independent reviews essential for safeguarding the best interests of the plan. Given the significant impact of medical and pharmacy claims on the balance sheet, accurate processing and adherence to negotiated rates and prices are imperative. Audit reports help you do your job better if you’re in-house managing a plan.
The most prudent approach to overseeing claim payments for self-funded plans is through continuous monitoring services that yield savings exceeding their cost. An increasing number of plans now utilize audit software to catch errors in real-time while enabling enhanced oversight of TPAs and PBMs. This proactive monitoring approach allows sponsors to manage their plans more effectively, minimizing issues that may only surface during a delayed audit. With plans increasingly prioritizing the active management of claim payments, they are better positioned to achieve favorable results.
