Large corporate and nonprofit employers sponsoring benefit plans know that medical claim auditors have made great strides in increasing the accuracy of their service. Gone are the days of random sample audits as the gold standard, and today 100-percent of claims are reviewed. Testing the accuracy of all payments against the plan's covered services and price agreements is a significant job that auditors now complete with remarkable speed. As a result, they flag overpayments, mistakes, and other irregularities down to a fine level of detail. The data is excellent oversight of third-party claim administrators handling payments.
It might surprise people new to the field and only familiar with today's claim audits that the process began as a regulatory requirement. Today it's a management function responsible for saving large plans hundreds of thousands of dollars annually – some into the millions. Advances in technology and software have brought improvements and the rise of firms specializing in the service. You can find generalist audit companies that review claim payments, but their expertise can't match the full-time claim auditors. Many have experience with large health plans that they bring to the current work.
Although TPAs and PBMs (pharmacy benefit managers) are famous for making accuracy and performance guarantees, only an audit can confirm them. Allowing administrators to self-police their work falls short on conscientious oversight, and only an independent review with nothing but your plan's best interests in mind is sufficient. Medical and pharmacy claims are a prominent item on the balance sheet and quickly affect the bottom line. It's why accurate processing and adherence to negotiated rates and prices are so crucial. If you're managing the plan in-house for the sponsoring company, audits help.
A continuous monitoring service that finds savings above its cost is the wisest approach to self-funded plan claim payment oversight. An increasing number of plans keep the audit software running in the background to catch errors in real-time. It also allows for an unprecedented oversight of TPAs and PBMs, allowing sponsors to manage their plans more actively. Without monitoring, much more goes unknown until it's flagged in an audit longer after the fact. It's why plans increasingly monitor their claim payments and manage themselves more actively for better results.
