Frequent Claims Audits Protect Health Plans

In the early years of self-funded health and pharmacy benefit plans, auditing was primarily seen as a matter of regulatory compliance. However, that perspective has evolved significantly, mainly due to advancements in medical auditing technology. Nowadays, there's even PBM RFP consulting, and the capability to scrutinize 100% of claims represents a significant shift from the traditional method of random sampling. Specialist auditors now leverage high-tech software, enabling them to review each claim with remarkable precision by checking it against hundreds of criteria for improved accuracy.The reports generated from this level of detailed analysis are often eye-opening, showcasing the tangible benefits of enhanced auditing efforts for better managing health plans. Auditing plays a pivotal role in any financial transaction, and medical and pharmacy claims are no exception. These claims are processed according to each plan's provisions and are influenced by various factors, including negotiated provider rates and rebates from pharmaceutical firms, creating a complex landscape. Claims typically go through large health plan systems, and errors can occur; sometimes they are substantial.Claim auditing helps identify mistakes that can significantly cost plans. The independence of the auditing firm you choose has a considerable impact on the quality of the reports they produce. When an auditing firm is solely focused on advocating for your plan, it meticulously delves into the details. Since claims processing involves many components, making minor improvements can lead to substantial enhancements. Audits identify past mistakes and help prevent similar issues in the future. For professionals reporting on budgets and plan performance, these audit reports are invaluable tools.It's crucial to conduct implementation audits with new third-party administrators and pharmacy benefit managers. Active oversight through auditing serves as the best line of defense for self-funded plans against cost overruns and erroneous payments. Depending on the plan's size and complexity, potential recoveries from audits could reach millions of dollars. Importantly, there's a significant improvement in member services as well; effective auditing ensures that claims are paid correctly and that all members receive equal treatment under the plan. By prioritizing audits, you're assuring your plan's success.