One-Size Does Not Fit All in Claim Auditing

One-Size Does Not Fit All in Claim Auditing

When considering the complexity of most employer-sponsored health and pharmacy benefit plans, it is clear that oversight must be tailored to each situation. The most effective medical claim audits examine every plan detail and review all claims. A one-size-fits-all approach will undoubtedly compromise outcomes and plan sponsors to seek better performance. Large employers who self-fund their plans have significant financial stakes and require accurate claim payments. Many turn to third-party administrators, and auditing is the best way to achieve the necessary oversight.

Claim audit companies often employ experts with backgrounds in large health insurance carriers, bringing valuable knowledge about claim payments and a deep understanding of how to set up audits effectively. Utilizing advanced auditing software to review all claims ensures unmatched accuracy. Approaches like random sampling or anything lacking customization will not yield the same results. Accurate claim processing ultimately benefits all members and provides equitable treatment. Successful health plans frequently conduct audits of their own operations to catch overpayments.

As claim payment systems evolve, it is prudent to encourage your administrator to prepare for auditing. While any system can be reviewed, those ready for audits simplify the process and reduce costs over time. Although the value of claim audits has shifted toward being a management resource, it's also important to recognize existing regulatory requirements. Meeting these requirements while discovering cost-saving opportunities and recovering overpayments creates numerous advantages for your plan. Even if claim administrators assert they perform self-audits, verifying their claims is wise.

Just as auditors uncover financial recovery possibilities in medical plans, they can do the same for pharmacy benefit plans. For instance, when formularies specify generics but name-brand drugs are dispensed instead, the costs can add up quickly. Audits that identify such errors and assist plans in recovering funds are financially advantageous in the long run. Additionally, addressing recurring systemic errors can lead to significant savings—auditors who identify these issues can drive considerable reductions over time. Customized audits yield impressive results and enhance claim administration.