Most employers large enough to self-fund their health plans do so intending to save money. The opportunity exists, but are you maximizing the savings? Given everything that's happened in the wake of the pandemic, using medical claim auditing services for a thorough review is wise. Having professional auditors review all your claims gives you an accurate picture of many factors. It provides insight into processing errors, medical billing, coding issues, and so much more. Most plan sponsors audit more routinely now than in the past. It's a budget-friendly process that improves plan performance.
The most productive audits begin with an initial meeting to ask and answer questions and lay out specific goals. They figure prominently in the audit setup, improving the final report's accuracy and insightfulness. Better auditing firms study your plan's provisions and ensure they are explicitly reflected in the claim review. Most outside claims processors are health plans with their own provisions, and confirming they're observing yours is essential. As thousands of claims are paid, often for costly services, minor issues can add up. When auditors flag them, it can be an eye-opener.
Finding costly claim processing error patterns and making systemic fixes is what gets the most attention after claims audits. It's unsurprising because it represents the most significant financial recovery opportunity. But when all claims are reviewed and every error noted, there are opportunities for many more recoveries. It's a value-add that has occurred with continuous advances in software and audit system technology. The electronic portion of claim reviews becomes more sophisticated yearly, and you can expect more detailed reports. The new normal is a higher level of accuracy.
When it comes time to plan an audit, it's helpful to interview several firms. Consider one if your current auditor isn't a specialist in the field. Claim auditing requires dual expertise in audit and medical billing. Untangling claims processing and payment errors requires more than financial knowledge. It's a process involving medical services and the charges for them. For example, some tests duplicate each other, and one patient does not need more than one. Unearthing situations like those and bringing them to providers' attention can be helpful, and it helps prevent the same errors from repeating.
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