The value of medical claim audits gained prominence after the COVID-19 pandemic. It’s more widely acknowledged that detailed claim reviews generate valuable insights into healthcare costs. Audits’ clear and comprehensible reports are now essential, ensuring that the data provided to employer-sponsored plans is accurate and straightforward to interpret. When interviewing audit firms, it is crucial to inquire about their reporting methods; firms that present data clearly will enhance the overall value of their services, allowing you to utilize the information obtained easily.
Plan sponsors can start by developing a list of deliverables they expect from the audit process. Beyond identifying errors, auditors can engage in a mutually agreed-upon evaluation based on their unique skills. If your third-party processor is not conveying critical aspects of your claim experience, auditors can effectively bridge this gap. When findings are presented in concise reports highlighting the essential details, these documents become valuable tools for managing plans. It’s worth considering continued engagement with the audit service for additional insights even after the initial audit.
The growing importance of thorough claim reviews stems from the concept of 100 percent auditing. This level of scrutiny provides results that far exceed those from random sample methods. Moreover, when supported by advanced electronic systems, audits can be performed quickly and affordably. Few services can yield financial benefits like claims audits can, as the recoverable errors they identify typically outweigh the audit costs. Who gains the most from auditing? Primarily employer-funded medical and pharmacy plans that have outsourced claim administration to third-party processors.
Most claim administration service agreements include performance guarantees, but how often are these commitments actually fulfilled? Regular or continuous audits can ensure that promises are met and highlight improvement areas. Ideally, every claim should be settled accurately on the first attempt, and by refining systems to accommodate specific plan provisions, the likelihood of future errors can be significantly reduced. Modern audits encompassing all payments and undertaking thorough verification represent a valuable investment in effective plan management.
