Health Plan Claim Audits are Increasing

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New member
Jan 17, 2023
The coronavirus pandemic turned things upside down financially for many health plans, with increased utilization and astronomical costs for some treatments. In its wake, are one of the ways plans have conducted post-mortems on their experience. The impact of a once-in-a-century event can't be overstated, and where there were mistakes and overcharges, the opportunities for recoveries were significant. A thorough review of medical and pharmacy claims will turn up irregularities of any kind and can lead to both recoveries (that can be substantial) and processing system improvements.

Claim audits that might have been annual or tied to regulatory and compliance requirements are being moved up or conducted more frequently. It's an excellent way to manage more actively and conduct oversight of third-party administrators and pharmacy benefit managers. The large companies providing claim administration services to employer-funded plans have sophisticated systems, but even they can miss some details. Implementation audits are also wise because they can confirm whether all pieces are in the system correctly and whether claims are being paid accurately and fairly for all members.

Catching repeating errors in claim processing long before they become million-dollar problems is a priority for every self-funded medical and pharmacy plan. Once those are flagged and corrected, today's 100-percent auditing drills down to a detail level it goes beyond random sampling's general findings and pinpoints an impressive number of individual errors. As they are flagged and over or incorrect payments are recovered, cost containment goals become more easily achievable. While you can't stop medical cost escalation, managing a plan more accurately and maximizing the value of every dollar is possible.

Audit forms specializing in health plan claims have developed considerable expertise recently. The powerful and proprietary software they bring to each project goes a long way toward improving audit accuracy. When electronic reviews are thorough and accurate, it also reduces the staff tie required to analyze the findings. Factual data with exact numbers speaks for itself, and when you have a thorough audit report in your hand, you've conducted comprehensive oversight. In-house plan managers are more effective and efficient when working with specialist auditors who know claims.


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