What Makes the Most Accurate Claims Audit?

Posted by TFGPartners on February 26th, 2021

It wasn't very long ago that self-funded corporate medical plans were audited with random sample methods, and only as often as required by the government. Thankfully it's much different today as facility claims auditing now can review 100-percent of the medical and pharmacy claims paid. There is far greater accuracy, less work for a company's in-house benefits staff, and an easier time managing plans better. Advances in software that began in the '90s and have continued up to today have brought significant improvements in audit techniques. It helps control costs and makes plans perform better.

When senior management and financial analysts review a company's exposure to unknowns, medical costs are high on the list. It's why the earlier random sample audits conducted long after medical and pharmacy claims were paid left much to be desired. There were times when large cost increases hit earnings reports and affected stock prices. Now most companies understand it is in their interest to audit frequently and have a service monitoring their claim payments continuously. It allows errors to be caught and corrected quickly, keeping plans on track and lessening the need to recover overpayments.

The continuous monitoring service can bring the most significant leap ahead in better plan management. It provides real-time data about claim payment activity. When payments are checked as they occur, it's much easier to spot and fix errors before multiplying. There are far fewer problems with continuously monitored plans, and when increases do occur, they are understood quickly. The cost of the service is often far less than the payment mistakes it prevents. It also helps companies meet the promise made to employees for an efficient, effective plan. Everyone benefits when plans run smoothly with fewer errors.

The increasing use of continuous monitoring is a testament to the plan performance improvements it will produce. Claim processors make promises about accuracy and may have the best of intentions, but nothing replaces oversight. It's human nature to be more careful when you know someone is checking, and it applies easily to medical and pharmacy benefit claim payments. When in-house plan managers have factual data in hand, the discussion about mistakes and overpayments is fact-driven and can't easily be disputed. Monitoring data also helps answer questions from in-house finance team members.