Tailor a Claim Audit to Your Health Plan

Employer-sponsored health and pharmacy benefit plans are crucial elements of employees' overall compensation packages, demanding vigilant oversight to ensure the accurate processing of claims. The specialization of most of these plans requires customized oversight, particularly regarding medical claim audits. The most effective audits consider every nuance of a plan and thoroughly review 100% of claims. Using a standardized, one-size-fits-all approach can diminish the results, and plan sponsors seek better outcomes. Therefore, customized claim reviews are the most popular.

Large employers that self-fund their plans have significant financial stakes and require that claims be paid accurately. Many sponsors rely on third-party administrators, where auditing becomes the optimal way to ensure needed oversight. Claim audit firms with seasoned experts on staff, especially those with backgrounds at large health insurance carriers, bring specialized knowledge. They begin the auditing process with a clear understanding of the setup, facilitating a more thorough and compelling review. Sophisticated auditing software reviews 100% of claims and can deliver unmatched accuracy.

Accurate claim processing serves the best interest of plan members and ensures equitable treatment for all. Well-managed health plans frequently conduct self-audits to maintain high standards of accuracy. In the current landscape of claim payment systems, it's prudent to encourage third-party administrators to establish an audit-friendly setup. Systems designed with features optimized for efficient claim payment reviews can lead to smoother processes and reduced costs in the long run. While claim audits primarily serve as a management tool, they also fulfill regulatory requirements, thus meeting dual needs.

Plans can benefit on multiple levels by satisfying these standards and identifying cost-saving opportunities. As such, it is essential always to verify claim administrators' promises of self-audit capabilities to maintain the integrity of the process. Additionally, auditors can identify and flag recovery opportunities within pharmacy benefit plans. For example, when formularies require generics but name-brand drugs are dispensed, it can increase costs. Audits that pinpoint these mistakes and help plans recover overpayments can yield substantial financial benefits in the long run, when totals become significant.