All well-functioning and optimized medical and pharmacy plans need a healthcare audit routinely to check their claim payment accuracy. With outside claims processors handling administration, it's necessary to conduct oversight as a built-in part of operations. There's every reason to celebrate the single-digit error rates administrators and their systems achieve these days. But even low single digits are enough to matter financially and for member service. The technology-driven audit systems of today can find error one-offs along with deeply buried systemic issues responsible for repeating mistakes.
It takes a specialized approach for each benefit plan. For example, understanding the complex coding of medical billing is as much a requirement as knowing the discounts and rebates of a pharmacy plan. The best auditors arrive knowledgeable on all topics and carefully add any unique provisions from your plan. When they run a claim review that checks every payment, it's easy to re-run with added questions answered for an apples-to-apples comparison. Using the same auditor and their system over time allows year-to-year comparisons that spot cost trends in their infancy and prevent more significant issues.
Most large corporations and nonprofits self-funding employee benefits welcome the chance to review their claims payments with an eye toward savings. Audits help the bottom line, and while they are expense items, the net result is revenue-positive – recovering overpayments and preventing future errors totals far more than the audit service's price. Senior executives answering to boards and shareholders also appreciate the thorough data audits produce. If there are questions about expense increases or budget variations, it's easier to answer with factual data. It's better than generalizing.
The independence of your claim audit firm also matters. When their only allegiance is to your plan, you can have greater confidence in the data and reporting. Implementation auditing is also helpful when you switch to a new claim administrator, regardless of which benefit plan it covers. Large processors add your plan to their system, which already has a default setup. Needed customization improves performance for your plan's claims, and auditors can double-check to ensure it's been done well. Minor adjustments can add impressive savings when the systems are optimized and members are served better.
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