Something new arises with health planning billing errors and related irregularities when you think you’ve seen it all. Medical claims auditing is one of the most effective ways for employer-funded plans to run oversight and keep their claim administrators working at peak accuracy. Many TPA agreements these days indeed include self-reporting on errors, but how well can it work when the system that makes the errors is used to detect them? It’s evident to anyone that independent oversight from a third-party auditor will give you more accurate results. Today’s auditing systems are highly accurate.
Knowing where to look for errors is the most obvious reason to hire a specialist firm. People who build and run the systems that review medical claims daily are closest to it and stay abreast of changes and new developments. The COVID pandemic has upended many things, and medical billing is one of them. Story after story about astronomical costs appeared. But in less intense times, overcharges and overpayments occur, and policing them in real time needs to happen. It also explains why many plan sponsors audit more frequently today or have their claim payments checked monthly or more often.
Sophisticated audit software can pick up even buried mistakes that routine reviews might miss. If you’re in-house with a plan sponsor, use your pre-audit meeting to voice any concerns or considerations you want your auditor to review. If you audit a medical and pharmacy plan simultaneously, you’ll have the best opportunity to maximize your savings. You can easily expect the recoverable mistakes an audit will find to be several times more than its price. It’s surprising to many people at first, but seeing is believing, and after your first claim review, you’ll understand – that even low error rates are worth improving.
Human nature is to work harder when there is active oversight, which makes the case for claim auditing. Plans that review their payments independently can easily expect better performance from third-party administrators and pharmacy benefit managers. No one enjoys being called on the carpet; doing it has a short- and long-term impact. You also can operate more knowingly as a plan sponsor when you have an auditor’s report in your hand with the facts. Nothing speaks louder, and you’ll feel more confident knowing you have an objective opinion from an audit firm with only your interests in mind.
