Getting the most out of medical claim auditing for your plan means putting all aspects of the auditor’s report to use. You need to understand the findings quickly; the good news is it’s becoming easier. Two parts of medical (and pharmacy) claim reviews have improved in recent years. One is the readability of the reports, and the other is checking 100 percent of claims – it’s better than random samples. Assessing your self-funded plan’s performance boils down to claim payments and their accuracy. When claims are correctly paid, you better contain costs and service, plan members.
If you’ve been managing benefits plans for some time, you’ve been around for the advances in auditing that have been transformational. The improvements in software and systems have made it easier to audit and have clear reports that point to opportunities. Better auditors will work with you after their review to make systemic corrections that prevent errors from multiplying and flag other opportunities to improve. Medical and pharmacy claims each have hundreds of variables, and opportunities for mistakes come with each. No matter how effective your third-party administrator is, there will be errors.
Adding continuous monitoring services with the same software and systems as audits has become increasingly popular. Nonprofit and corporate employers large enough to self-fund their plans have much to gain from better plan management. Running oversight of third-party administrators brings many advantages, not the least of which is understanding the more active management interest. In a corporate setting where C-suite executives live and die by quarterly earnings reports, the surprises prevented (or explained) by the monitoring service can be helpful. Health plans impact the bottom line.
Implementation auditing continues to be another essential element because it catches errors before they multiply. There are many business expressions about preventing million-dollar problems, and they work well with claim reviews. The chances for more accurate claim processing improve when you get off to a good start. Because most third-party administrators are large health plans, they already have systems, but your plan’s rules may vary. Making sure the details are adjusted can be a significant undertaking, and only a 100-percent claim review can confirm whether they are happening.