Large and mid-sized corporations with self-funded medical and other benefit plans handled by outside administrators can encounter a lack of transparency in claim payments. It makes medical claim auditing services crucial for maintaining profitability and ensuring that employee plan members receive the services they expect. Medical expenses represent one of the most substantial costs for corporations. Unlike other significant expenditures, these costs do not contribute to building infrastructure or equity. Through meticulous auditing and monitoring of claims, there are chances to wisely manage costs.
Claim auditing is increasingly viewed as a strategic management tool with several advantages. In the past, many plans performed only the minimum necessary audits, mainly for compliance with ERISA and other regulations. Nowadays, more proactive benefit plan managers conduct sophisticated audits encompassing 100% of claims paid. Their goal is to address systemic errors and recover overpayments or incorrect payments. While claim administrators promise accuracy, mistakes are common and can lead to financial losses that ultimately do not support employees. Auditors can flag them for review.
Thorough audits can help companies recover more than just the cost of incorrectly paid services. They can lead to improvements in the benefits plan and reallocate funds back into corporate budgets. Typically, the amounts recovered through 100% audits and ongoing monitoring far surpass the fees paid to auditors. Since the 1990s, top-tier medical and pharmacy benefit auditors have reviewed all claims and refined their techniques and software. There are differences between auditing firms, and only those with advanced technology can identify the most errors; simply reviewing all claims is insufficient.
With the continuous rise in healthcare costs in the United States, ongoing monitoring following an audit is increasingly popular. This approach often employs software like those used during audits, allowing for real-time review. Errors and irregularities can be detected promptly, enabling interventions for small issues before they escalate. This practice mainly benefits employees enrolled in high-deductible plans, as many administrators can implement corrective measures immediately. Access to accurate information empowers plan managers to recover overpayments, control costs, and enhance service.
