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The Surgical Precision of Today's Claim Audits

Reviewing its claim payments is essential for any organization sponsoring benefit plans, whether corporate or a large nonprofit. For example, medical claim auditors today have more powerful software and systems to review every payment and check for thousands of variables. The same goes for pharmacy plans for formularies, discounts, and rebates, which are worthy of scrutiny versus what was dispensed to plan members. Changes occur within each plan year, and claim payments must keep up. Usually, things go as planned and promised, but then they do not, and auditors can flag the discrepancies.

Health and pharmacy benefit plans aim to provide excellent care for members at the lowest possible cost. Claim payments are one way to measure whether the promises are kept and expenses are managed carefully. Sophisticated audits can untangle complicated claim payments and explain whether plan provisions are followed. For example, some tests and treatments overlap or duplicate others. Proper care coordination ensures it doesn't happen, but it can occur if the coordination is absent. An audit can flag the times it has, allowing requests for reimbursement and better planning.

The independence of audit firms is central to their work and effectiveness. When they do their jobs well, their reviews and reports are clear and insightful. Specialist firms working in the field are among the best because their senior team members often have medical billing expertise. The original auditing charge was for tax and financial purposes. Medical claims differ because they require an understanding of specifics like coding overlayed with the numbers. You can quickly see that added expertise in medical billing is helpful. The pharmacy claim world is equally complex because of pricing arrangements.

If you're in-house at a large employer sponsoring its benefit plans, you may want to time your audits to make reports available before budgeting or renegotiating. If you're working on a new agreement for claims administration or reviewing cost trends in medical services or medicines, having an auditor's report in hand can help. It gives you data on which to base your decisions and backup for any requests you may be planning to make – especially ones related to improvements. Each plan year is different, and working with the same auditor, allowing you to compare each year's results, is often a helpful approach.


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