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Containing costs and serving members better (and equally) are among the many excellent reasons to review medical plan claims with a healthcare audit. Nothing compares to an auditor's independent review of your claim payments. It produces factual reports that cover every aspect of your claim administrator's work. It's excellent to compare an auditor's findings with your administrator's self-reports. When the two reports agree, you can have great confidence. When there are discrepancies, the auditor will direct you to where the irregularities occurred, individually and repeating group errors.
Recently, there has been a spate of class-action lawsuits accusing employer-sponsored health plans of breaching their fiduciary responsibilities. Auditing helps you adopt "best practices" and have a leg up if such a suit targets your plan. Spending plan funds accurately and serving members equally is the goal; claim audits prove you're doing it. If not, their flagged errors give precise direction about how and where to improve. Not long ago, claim auditing ran on random sampling that left much to be desired. Because the samples were random, each differed by definition from the prior one.
Since the arrival of 100 percent claims audits, accuracy has improved dramatically. Now, you can compare apples-to-apples over the years and see performance improvements or areas of concern. Today's Audit systems and software are also far more powerful thanks to continuous technological advancement. Use the pre-audit meeting to bring up questions and areas of concern that auditors can check. The more claims payment reviews are customized, the more accurate and valuable they are. When you switch to a new claim administrator, remember an implementation audit after 90 days to confirm their accuracy.
The member service dimension of claim reviews is about assuring equal treatment. If one member's claims are paid differently than another's, someone is receiving more than someone else. When audits improve accuracy rates, there is confirmation everyone is receiving the same treatment. If there are sudden cost increases straining budgets or an extraordinary, unexpected event like the COVID-19 pandemic, plans routinely auditing are in better shape. It's also why some employer-sponsored plans now have real-time claims auditing. It monitors payments and reports the findings monthly.
Recently, there has been a spate of class-action lawsuits accusing employer-sponsored health plans of breaching their fiduciary responsibilities. Auditing helps you adopt "best practices" and have a leg up if such a suit targets your plan. Spending plan funds accurately and serving members equally is the goal; claim audits prove you're doing it. If not, their flagged errors give precise direction about how and where to improve. Not long ago, claim auditing ran on random sampling that left much to be desired. Because the samples were random, each differed by definition from the prior one.
Since the arrival of 100 percent claims audits, accuracy has improved dramatically. Now, you can compare apples-to-apples over the years and see performance improvements or areas of concern. Today's Audit systems and software are also far more powerful thanks to continuous technological advancement. Use the pre-audit meeting to bring up questions and areas of concern that auditors can check. The more claims payment reviews are customized, the more accurate and valuable they are. When you switch to a new claim administrator, remember an implementation audit after 90 days to confirm their accuracy.
The member service dimension of claim reviews is about assuring equal treatment. If one member's claims are paid differently than another's, someone is receiving more than someone else. When audits improve accuracy rates, there is confirmation everyone is receiving the same treatment. If there are sudden cost increases straining budgets or an extraordinary, unexpected event like the COVID-19 pandemic, plans routinely auditing are in better shape. It's also why some employer-sponsored plans now have real-time claims auditing. It monitors payments and reports the findings monthly.