Manage a Health Plan? Audit Claims Often

With millions of dollars are involved each year, effective oversight of employed-funded health plans becomes critical, particularly in the realm of medical claim auditing. Pharmacy claims also warrant scrutiny. Recent improvements in audit systems promise substantial progress and adapt to the evolving medical billing landscape. As this vast industry grows, employer-funded health plans face increasingly intricate charges yearly. Although many claim administrator agreements include self-reporting clauses, the necessity for independent oversight is clear—it ensures that administrators perform at their best.

The setup of audits is crucial; if you manage a health or pharmacy benefit plan in-house, it’s essential to approach this task with seriousness. Experienced firms know what to investigate and will respect the unique aspects of your plan. Holding a pre-audit meeting to outline your objectives and concerns is always wise. If you’ve had uncertainties regarding items from your claim administrator, an auditor can delve deeper and provide clear feedback. Ideally, this will confirm that everything is operating smoothly and correctly. However, you’ll have concrete evidence to address issues if issues arise.

Extraordinary circumstances, such as the pandemic, show the importance of claim auditing as a safeguard against mistakes and overcharges. Error rates commonly remain in the low single digits, yet uncovering discrepancies can lead to significant savings, including recovering erroneous payments. The goal is implementing updates and fixes within the processing system to eliminate such errors. Even the best systems can experience glitches, especially if billing has evolved and require adjustments. Each year presents unique challenges, and auditing helps identify what your processor might overlook. 

Many plans regularly audit or continuously monitor their claim payments to stay informed. Although repeating error patterns are less frequent today, they can still occur. Often, auditors are the first to identify these patterns and can assist in rectifying the system to avert future errors. It’s always wiser to prevent mistakes than to seek reimbursements afterward. Ensuring accurate claim processing is crucial for members relying on co-payments or other cost-sharing arrangements, preventing improper out-of-pocket expenses and benefiting the plan—it’s simply part of effective management practices.