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Why Not Audit Claims All the Time


Given the budget-friendliness of medical claim audits today, they add to the bottom line, not subtract from it; more plans are auditing continuously. When employers sponsor their benefits programs, they do so for many good reasons. But along with the advantages come risks in the form of exposure to high costs. Therefore, keeping tables on claims payments matters, especially in an era of never-ending cost increases. Outside claim administrators self-police and report findings, but nothing compares to an auditor's independent review. It's the best way to run needed oversight of every plan's performance.


Lately, there have been some once-in-a-lifetime events with medical billing, chiefly due to the coronavirus pandemic. It highlighted the urgent need to manage self-funded medical and pharmacy plans actively. Gone are the days when outsourcing claim processing means your company can relax its oversight activities. Wildly inflated charges for some routine treatments and eye-popping prices on newer or experimental therapies made headlines. Employers funding their benefit plans were on the front lines paying the costs. The most challenging to understand were those that varied by provider.


The best-run employee benefit programs are actively managed by their sponsors. Using audit capabilities to monitor payments for medical services and pharmacy products means you're always on top of what's happening. When you spot cost trends in their infancy, you have a better chance of solving problems before they become extensive and expensive. It's a vast difference to audit long in arrears and occasionally come across million-dollar problems. When you have audit data in hand and meet with representatives of your third-party administrator or pharmacy benefits manager, it matters.


One of the critical factors in claim reviews is knowledge of medical billing. When you work with specialist auditors who bring that understanding, the possibility of an audit that significantly improves your plan's performance is higher. Effective auditing is about details; setting up a review that considers your plan's provisions is essential. In pharmacy auditing, factoring in promised discounts, rebates, formularies, etc., is also necessary to confirm whether the promises are kept. Because claims are numerous and payments can be complex, staying on top of every detail as it occurs is essential.


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