Paid Medical Claims Deserve Close Scrutiny

Managing health and pharmacy benefit claims is complex, and accuracy is crucial, given the expenses involved. As medical claims auditing has evolved, it offers sophisticated methods that allow for thorough claims reviews at a granular level. It helps plan sponsors, and their auditing firms identify numerous variables for evaluation, enabling them to answer more questions regarding claim costs with factual accuracy while analyzing and comparing results against other factors. The advancement provides plan sponsors with an exceptional ability to monitor claim processors effectively.

The rapid introduction of new tests and treatments amid a chaotic emergency during the COVID-19 pandemic underscored the importance of detailed audits. Rarely has the healthcare system faced such an unexpected and widespread financial burden. Employer-sponsored health plans were significantly impacted, making it essential to analyze the resulting expenses. This situation also illuminated the enhanced capabilities of claim auditors, which, while known, had not always been fully recognized. Consequently, detailed audits have become more common because of their return on investment.

Flexibility in claim auditing is vital, as varying plans are processed through different systems. It's essential to adapt audit capabilities, applying custom setups tailored to each plan's specific provisions and standards. There isn't a universal approach to claim auditing; anyone suggesting otherwise needs a better understanding of the complexities involved. Attention to detail is critical, especially with the savings and discounts promised by claim administrators. While self-reported information is useful, only a third-party audit can provide verification. Moreover, the audit setup is of paramount importance.

The quality of an auditor's system and methods significantly influences the overall outcomes. A well-organized and detailed structure that considers a plan's intricacies yields far more valuable insights than a quick, generalized audit. It also highlights the advantages of cultivating long-term relationships with auditors. With a deeper affiliation with a health plan, auditors can gain a comprehensive understanding of its unique nuances and may even propose suggestions for plan improvements based on their audit findings. It is a method that pays off in the long run.