Upgrading the quality of your medical and pharmacy plan oversight to follow best practices means it's time for a healthcare audit. An expert auditor reviewing your claim payments makes sense for any employer-funded benefits plan. Medical and pharmacy programs typically receive the most audit attention because the numbers are higher than other benefits. Experienced auditors have a cadre of irregularities they watch for and then can add your plan's unique provisions and check for them. The result is an audit report that digs deep into your plan's claim payment performance and any mistakes.
The coding required for medical billing adds a layer of complexity to the claim payment process, and although third-party administrators are knowledgeable, mistakes can happen. There are also updates and changes to stay abreast of each year, and auditors can double-check to ensure it is happening. The results may surprise you the first time an experienced firm reviews 100 percent of your claims. There are also opportunities to notify providers that you run oversight and will request reimbursement for errors. It's usually more accessible when you audit routinely and attempt recovery soon after the mistake.
Another way to follow best practices is to keep audit software running continuously. There's nothing else like monitoring claim payments in real time and receiving monthly reports. Take the recent pandemic as an example. Costs and utilization skyrocketed, and large employers' sponsoring plans were left to foot the bill. The ones with continuous auditing arrangements were better able to stay on top of things and question irregularities as they happened. They had many fewer million-dollar problems to clean up after the fact. Those plan sponsors could pay claims with more confidence in accuracy.
Planning and budgeting also become more targeted when you have clear audit reports to track changes and cost increases. When you're actively questioning claim administrators and providers, they naturally become more careful. Oversight plays a role in improving operations and actively managing your plan financially and its care delivery to members. Comparing an auditor's findings with your claim administrator's self-reporting can be enlightening when cost increases occur. You can also pose questions in your pre-audit meeting that front-load the process. It assures you'll have the date you need most.
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