Accuracy in the Details Improves Claim Audits

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Company Medical and Benefit Claims Auditing | TFG Partners

These days, nearly everyone in health plan management would agree that 100-percent claim audits are more accurate than random sampling. The improved accuracy means that a healthcare claims audit will flag more errors, discover additional overpayments, and lead to more precise reports. For plan sponsors, it's an opportunity to conduct oversight of third-party administrators and pharmacy benefit managers. The higher degree of accuracy makes the audit a more potent management tool, and it can help plans manage their claim costs. The processing function is complex and deserving of meticulous oversight.

Advances in the proprietary software used by specialist claim auditors drive many improvements and allow more details to be reviewed. The cost for the audit service is budget-friendly because they can recover up to four times as much as the cost for the service. It's a pleasant surprise to anyone working in the field who has not yet been on staff during a 100-percent audit. The former random sampling method was both more time-consuming and less accurate. Today's audit software makes quick work of thousands of claims and leads to precise data that's actionable with TPAs and PBMs.

Besides the goal of having well-managed health and pharmacy benefit plans, sponsors each year deal with a never-ending escalation in health care costs. Managing them while making sure plan members receive excellent care is the goal, and audits shed light on performance. It's common today for companies to keep audit software running at all times for real-time monitoring of claim payments. Nothing compares to catching and correcting errors in real-time – it's also easier to recover overpayments shortly after they occurred. Working months or years in arrears is more complicated.

It's an impressive evolution for claim audits which began as a regulatory compliance matter. Their efficiency and value to management have put them into far more frequent use, and the value they produce is undeniable. Better technology also means less human involvement in the review process, and each year it becomes better. Upper management with fiduciary responsibilities needs plans to be well managed, and auditing is a way to do it. It's natural for TPAs and PBMs to conduct their work more carefully if they know oversight is present. You can confirm if they are meeting performance guarantees.

 

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