Review Claim Payments for Every Detail
There is a growing consensus among health plan management professionals that conducting 100-percent claim audits is significantly more accurate than relying on random sampling. This enhanced accuracy allows medical claim auditing to identify more errors, uncover additional overpayments, and yield more reliable reports. For plan sponsors, it presents an opportunity to effectively oversee third-party administrators (TPAs) and pharmacy benefit managers (PBMs). The increased precision makes such audits a powerful management tool, assisting plans in controlling their claim costs.
Given the complexity of claim processing, it necessitates careful oversight. Advancements in software used by claim auditors have contributed to this progress, enabling a more comprehensive review of details. Additionally, the price of auditing services is affordable, as they often recover up to four times their cost. It comes as a pleasant surprise to those in the field who haven't experienced a full audit before. The previous method of random sampling was more time-consuming and less accurate. Today’s audit technology efficiently handles thousands of claims, delivering actionable data for TPAs and PBMs.
In addition to meeting plan management needs, sponsors face a continuous rise in healthcare costs each year. Balancing these costs while ensuring that plan members receive quality care is a primary objective, and audits play a crucial role in enhancing performance oversight. Many companies now keep audit software operational around the clock for real-time monitoring of claim payments. Identifying and resolving errors in real-time is incomparable—recovering overpayments is also much simpler shortly after they occur, rather than working months or years later, which can complicate matters.
The evolution of claim audits is noteworthy; what started as a means of ensuring regulatory compliance has transformed into a management tool that is increasingly utilized, showcasing its undeniable value. Improved technology continues to reduce the need for human involvement in the review process, enhancing its effectiveness. For upper management with fiduciary responsibilities, ensuring that plans are well managed is essential, and conducting audits is a valuable strategy to achieve that. It encourages TPAs and PBMs to perform their duties with greater diligence, knowing that oversight is in place.