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Oversight Matters for All Health Plans

Making a case for medical claims auditing for cost-containment efforts is easy. But there are many more reasons to consider its potential (and importance). One of the newest ones is fiduciary breach class-action lawsuits. They've begun to target large employer-funded health plans with accusations they are poorly managed on behalf of members. Another is regulatory and compliance requirements that mandate plans to run oversight. Regardless of which one you focus on, they are incentives to audit routinely and thoroughly – you'll also help the bottom line with error recoveries.

Auditing claim payments in near real-time is also trending. There are many reasons for this, and plans that monitored their claims payments fared better during the recent pandemic or were better able to question overcharges and recoup overpayments. The U.S. healthcare payer system continues to be under incredible strain, and plan sponsors can see millions go out the door unexpectedly. When auditors monitor claim expenditures, there's data to explain the expenses or confirm the self-reporting of claim administrators. The budget neutrality of claim auditing makes reviewing payments a no-brainer.

Sometimes, the results of a claim audit fall along the lines of what a claim administrator is self-reporting and flags errors that can be recovered. In other cases, it may turn up a significant number of irregularities and differ meaningfully from the administrator's reporting. In those cases, the audit's value skyrockets and leads to a review of the processor's methods and systems. Nearly all audits will find items of significance, and they may vary from year to year. As medical billing evolves, it's up to claim payers to keep up. Often, they do, but sometimes the change's pace is faster, making it more challenging.

Experienced claim auditors who work in the field daily arrive with a long list of items to double-check. But the best ones will carefully review your plan's provisions and include them in their review – no two plans are alike, and yours needs to be audited uniquely. The value of audits and the reports they produce increases exponentially with specificity. When you layer in your questions and have the audit check for them along with the routine factors, the value increases more. You may be surprised by the finding on the first try and in subsequent years as the audit firm continues its work.


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