Are you the in-house manager of a self-funded corporate or institutional employee medical plan that is self-funded? If yes, you understand the dual pressure to deliver outstanding services to plan members while controlling costs. Every claim paid must be accurate and within the parameters of covered services. Medical claim auditing firms are your best ally in the oversight and management of your third-party administrator (TPA). Using more advanced software and methods, they can help assure accuracy. Overpayments and mistakes in processing can quickly add up to significant amounts. They must be caught.
More self-funded plans than ever are working with auditors that review 100-percent of claims. There is no way random samples can compete with a complete review of every dollar spent. They also help plan performance goals – both in flagging errors and documenting performance in their audit reports and findings. There is also a beneficial effect on TPAs when oversight is complete and accurate. When in-house plan managers can have conversations based on factual data in hand, they are much more likely to lead to meaningful improvement. Most TPAs make accuracy guarantees, but oversight still helps.
Employee-plan members with high-deductible are also among those benefitting from claim payment reviews. Errors can cost them just as they cost the plan itself. As claim payment accuracy improves, they benefit equally. An ongoing monitoring service utilizing the same audit software and processes is also beneficial. It lets plan managers review claim payment performance continuously and stay on top of any mistakes or irregularities before they multiply. When upper management asks questions, or when there are cost increases, having reports and data with detailed explanations mean everything.
Given the amount of money on the line with medical plans and claim payments, it's easy to see why there continues to be a charge toward greater accuracy and accountability. What began as compliance with government regulations has grown into an essential management function. Surprise situations such as the COVID-19 pandemic, which caused many plans to take an unexpected hit, only increase the need for greater claim payment accuracy. Balance sheets and quarterly earnings reports can be easily affected by sudden cost increases for the plan oversight function to be overlooked.
