Claim Audits Can Root Out Every Mistake

The primary aim of medical claim auditing is to assist employer-funded healthcare plans in identifying improperly paid claims. Errors and irregularities can accumulate to significant sums, potentially reaching hundreds of thousands of dollars, depending on the size of the plan. This realization has driven a shift from random sampling to comprehensive 100-percent audits, which has proven to be a game changer. Instead of merely identifying substantial systemic errors that recur, contemporary claim audits provide an in-depth examination, producing detailed reports that enhance the audit’s value.

The advancements in electronic claim reviews powered by sophisticated software play a role in this process. Additionally, these improvements stem from specialized auditors’ expertise and claims administration experience. By merging auditing skills with claim payment knowledge, today’s systems are far superior to their predecessors. With the ability to identify more errors with less staff time within the usual operational timeframe, the benefits of frequent auditing are clear. This process aids employers in running oversight on claim expenses and budgets more accurately.

The factual data from audits is a reliable reference that is challenging to dispute. Therefore, many plan sponsors have discovered through consistent auditing that it is feasible to decrease error rates without incurring additional costs. Regular audits or continuous monitoring of claim payments facilitate adjustments to processing systems, contributing to heightened accuracy and quicker correction of mistakes. As these systems become more reliable, it is only natural for error rates to diminish, leading to a situation where nearly all claims are processed correctly the first time.

Ensuring equitable treatment for all members is essential for medical and pharmacy benefit plans, and accurate claim payments are a key component of achieving this. When claims are incorrectly processed, it can inadvertently lead to unequal treatment. Accurate claims processing ensures that all individuals receive fair treatment, aligning with the plan’s commitments and responsibilities. Furthermore, C-suite executives, often under scrutiny from boards or shareholders, benefit from the clarity and detailed insights provided in auditors’ reports, which offer clear explanations for fluctuations in claim costs.