Firms that focus on claim audits have improved their accuracy in recent years. If you’ve been relying on non-specialist healthcare auditing companies for medical claim reviews, it’s time to seek new proposals. You’ll notice better outcomes when audits are conducted using advanced systems and led by executives with extensive experience in health plans. Affordable claim audits have become essential for large employers that self-fund their benefit programs, whether for corporate or nonprofit purposes. Since your plan has unique provisions and standards, the audit configuration should be tailored accordingly. 

Currently, most claim processing is outsourced to large health insurance companies, which is logical due to their systems and negotiated provider rates. However, it can lead to claims being processed according to their criteria, potentially missing your specific needs. While it may result in financial benefits in some cases, it can also be detrimental in others. A thorough audit can sift through the details to ensure you receive the best value in all situations, and modern claim audits can now review 100% of payments. While all audits require attention to detail, medical claims have a unique two-dimensional aspect. 

There are standard financial elements to verify, but utilization issues also come into play. For instance, generalist firms only focus on the numbers during a tax audit, whereas medical and pharmacy claims involve additional factors. Examples of what claim audits can detect include duplicate tests, discounts, preferred rates, and non-covered expenses, depending on your plan’s payments. It’s advisable to conduct audits regularly if you haven’t done so already and think about continuous monitoring, which can utilize the same auditor’s software. Receiving data in near real-time is helpful. 

Implementation audits are particularly valuable when transitioning your claim processing to a new third-party administrator or pharmacy benefit manager. Despite good intentions, it’s common for details to be overlooked during such transitions. Once your plan is properly set up in the new system with your specific provisions included, you should see an automatic improvement in claim payment accuracy. It leads to the anticipated cost savings without any extra effort, establishing a framework to maintain those positive trends in the future. Routine claim auditing is a smart strategy for all health plans.