Picking the Best Claim Auditor for Your Plan

Many large for-profit companies and some government organizations operate self-funded health and benefit plans for their employees. With substantial financial stakes at play, medical claim auditing is essential for ensuring the adequate performance of these plans. Traditionally, auditors employed a random sampling technique to identify claim payment errors, which, while helpful, often missed a considerable number of mistakes, leading to less efficiency and less improvement to member services. Fortunately, specialist claim auditors have revolutionized the process and improved accuracy.

The introduction of comprehensive 100-percent audits has been a game-changer. These thorough audits provide precise data on all claims paid, enabling in-house plan managers to oversee operations more effectively. They also highlight payment errors, allowing organizations to implement strategies to prevent future mistakes. It helps control costs and ensures that funds are directed towards the promised care for plan members, preventing financial losses due to overcharging. A typical example involves dispensing name-brand medications when generic alternatives are available.

A 100-percent audit will catch all such discrepancies. Enhanced accuracy in auditing has allowed more self-funded plans to monitor claim payments, utilizing the same audit software continuously. Given the unpredictability of medical expenses, one of the best ways to manage costs is through real-time claims monitoring. If significant fluctuations impact earnings, the data can provide management with clear insights, helping to communicate all the details. Relying solely on retrospective audits can lead to unexplained expenses affecting the bottom line and potentially damaging company share prices.

The groundbreaking advancements of the 100-percent auditing method have fundamentally reshaped the industry. It has led to increased oversight and accountability as self-funded plans work to keep costs in check amidst continuous financial pressures. Negotiations with claims processors become more efficient when backed by factual data from every claim. With oversight in place, individuals tend to operate with greater diligence. Additionally, upper management values the budget neutrality of 100 percent audits, as they often identify errors that exceed the cost of the audit itself.