Greater Accuracy in Claims Auditing Cuts Costs
The self-funded medical and pharmacy benefit plans of large employers are intended to provide excellent health care to employees and their immediate families. They carry with them enormous costs, and medical claims auditing is on the front line of controlling them. Greater accuracy in claim payment auditing and continuous monitoring can make a significant difference on the bottom line. But it is doable thanks to advances in software that improve audit accuracy and check 100-percent of claims paid. Even when claim processing is outsourced, it lets in-house plan managers provide proper oversight.
There are audit firms that specialize in reviewing claim payments. Many are staffed by people with significant prior experience in the health care industry. It allows them to refine and improve their software and review processes – electronic and human reviews – to a point where they have remarkable accuracy. The most competent companies use claim audit firms like these instead of generalist auditors that may work in many areas. Nothing substitutes for the day-in/day-out experience of those who concentrate narrowly on the claim payment field. They help control costs and serve members better.
The trend is to outsource claims payments to third-party administrators (TPAs) that are often large health plans. While they bring considerable expertise to the table, mistakes are not unusual and may go undetected unless they are identified in an independent audit. With healthcare and drug costs skyrocketing and companies under never-ending pressure to deliver profits, they need to manage the plans closely. It's what led to 100-percent audits rather than random samples. As soon as software advances made it possible, the biggest plans were double-checking 100-percent of their claims paid.
The latest development in this high-stakes field is the continuous monitoring of claim payments. It uses audit software and works in nearly real-time. Mistakes that previously would have gone undetected until an audit (and multiplied) are routinely caught early. If providers increase prices or change the way of billing, it can have a considerable impact. Picking it up early allows questions and negotiations to occur that can avoid a spike in claim costs. Plans members also benefit from close management, especially those with high-deductible coverage. It's a given that accuracy brings multiple benefits to every plan.
