When your company sponsors benefit plans that pay millions of dollars in claims each week, it's essential to run oversight. Medical claim auditing and a similar program for pharmacy payments are some of the best ways to do it. When a professional auditor double-checks your claim administrator's work, you can have more confidence in its accuracy. When you're auditing your plan frequently, you'll also have data on cost trends in their infancy. One of the most challenging situations is to find yourself over budget with runaway expenses and little information – knowledge is power with claims.
The excellent big-picture news in claims auditing is that many processors are more accurate than ever. It's a refreshing change from the days when the best oversight method was random sampling, and there was variation in its accuracy. Each time you pull a random sample of claims to audit, it's unique. When every claim is double-checked, it produces a consistent result. It also facilitates clear comparisons from year to year to understand trends and expense experience. There is also a member service dimension, and audits help ensure members are treated fairly and consistently, which is the right thing to do.
Managing your benefit plans actively and asking probing questions of claim administrators is crucial. They are gatekeepers between your company's money and providers charging for their services. When administrators play their role effectively, they can help manage expenses and ensure members receive promised medicines and medical services. Duplicate and overlapping services also drive up costs, and questioning them cuts expenses. When providers are on notice you're watching, they will take care to coordinate care better and avoid overlapping charges. It cuts costs short and long-term.
Benchmarking against similar employer-funded benefit plans can also be enlightening. Your auditor can provide such information when they work with multiple plans. Knowing what is within and outside the acceptable range quickly clarifies the areas of most concern. Data-driven reports that are easy to read and understand provide factual proof of irregularities. Such a report is valid if you have status meetings with your company's claim administrator. It's also a way to run oversight on self-reporting if your processor provides such a service. Immediately, your meetings become productive.
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