Health Plans Need to Audit Claims

If the recent coronavirus pandemic made one thing clear, it was the value of healthcare auditing companies. When new treatments and wild fluctuations in charges suddenly came up, the usual answer was to pay and audit to follow up. The claims' findings led to the recovery of overpayments and negotiations to recoup funds from excessive charges. Providers and payers each were thrust into unknown territory and using every tool available to deal with the aftermath was essential. The experience gained from the claims reviews helps the present and future processing.

Even before the pandemic hit, there was a trend toward more frequent and thorough auditing. As employers that sponsor plans, both nonprofit and corporate, deal with ever-tighter budgets, making sure errors are caught and corrected makes more difference. There is a perennial need to make improvements and see costly mistakes as a way to blunt the effect of rising costs. Member service also depends on accurate claim payments so that all are treated equally. Those with high deductible plans also benefit from accuracy because it ensures they are getting benefits and not overpaying.

Claim audits today commonly find errors worth four times their price. It's an eye-opener for senior managers who may question the value of frequent claim reviews. They help tighten up plan management and ensure that systemic errors are corrected. It's worth noting the significance of catching mistakes soon after they occur. Recoveries are generally more straightforward, and there is much less work in reconstructing the situations if there are questions. Better software today also reduces human involvement in claim audits. When the initial electronic review is highly accurate, it makes a difference.

Independent specialty audit firms are increasingly dominating the claim review industry these days. They include people with health carrier experience and expertise in claims. They produce results superior to those from large generalist firms, and they have no allegiances except for your plan. It's not to say that others aren't honest, but there is a greater comfort level when the only business relationship is with your plan. It will be refreshing if you've never seen them in action and read a report after a 100-percent claim review. You'll have a description and data you can put to use immediately.