© Copyright khedmeh Wall
Employer health plans with outside claim administrators commonly depend on medical claim auditing for needed oversight. When claims are paid out of the house, double-checking their accuracy and that of your processors is paramount. However, there are many efficiencies an auditor can recommend based on knowledge of the field. You want an audit customized to your plan but aware of industry "best practices" that can help you improve. Every medical and pharmacy plan aims to provide excellent care to members at the lowest price. When auditors confirm it's happening, you'll have greater confidence.
As you set yearly performance and budget goals, you might consider sharing them with your audit firm. If they are monitoring your claim payments weekly, monthly, or with quarterly audits, they can help you understand whether you're staying on track. Claim administrators can help, but their reports come from the base system. An audit firm checks independently with a fresh set of eyes and different criteria. They also review all processors' work and can give you insight into strengths and areas of improvement for each one. When you're armed with data and understanding, you're also in a stronger negotiating position.
Claim audits began with random sampling and have evolved to highly sophisticated electronic reviews running on proprietary systems. Today's standards are double-checking and reviewing every payment for all relevant data points. It provides an unmatched level of accuracy and can answer virtually any question about claims paid. Even as claim administers police mistakes and self-report about accuracy, auditors take the process a step further. They are an independent review and run their check with different software. The processor self-reporting originates from the system that made the errors.
Every health and pharmacy plan self-funded by a large corporate or nonprofit employer has specific provisions. They determine what gets paid and what doesn't. It's easy for large health plans acting as claim administrators to take a cookie-cutter approach and use their provisions while overlooking others. Knowing this tendency reinforces the rationale for frequent auditing to keep payments on track. It also meets fiduciary responsibilities and ensures all members are treated equally. When a claim is paid in error, it's common for one member to receive benefits while others don't. Accuracy levels the playing field.