tfg seoThe frequency of benefit plan claim audits is a common consideration for plan managers, especially for those running self-funded plans. The demand for a healthcare audit is increasing, with claim reviews now occurring more frequently. This trend is likely due to sponsors recognizing the value of oversight, especially as many have outsourced processing to third-party administrators and pharmacy benefit managers. Each plan has unique provisions that must be loaded onto a payment system flawlessly. Reviewing claims often shows opportunities for improvement as systems are refined and improved.
It’s crucial for sponsors to conduct audits to recover incorrect payments, as large amounts of money are involved daily. A significant recent development in the field is continuous monitoring, using audit software in real-time to detect and flag irregularities. Detecting and rectifying as many mistakes as possible is essential for efficient plan management. Ensuring accurate claim payments is vital for managing costs, as they significantly impact expenses. Well-managed claims processing capabilities are vital during unexpected events, such as the coronavirus pandemic, enabling plans to stay on track.
Those with long experience in managing health plans may recall the initial random sample audits which required a substantial amount of human oversight. Today, the electronic portion of an audit checks all claims paid for hundreds of data points, showcasing significantly improved accuracy. Auditing is now viewed as a management tool rather than just a compliance issue, aiding in containment and improved reporting. The opportunities exist for cost containment and member service improvements. Both are helpful for employer-sponsored plans in the new era of class-action fiduciary breach lawsuits.
The trend towards outsourcing claim processing coincided with advancements in audit technology. When claim payments were handled in-house, sponsors had an easier time ensuring accuracy since they controlled all the data. With third-party administrators and pharmacy benefit managers now in control, audits play a crucial role in conducting oversight. With the pressure to contain costs against rising healthcare service prices, accurate claim processing is increasingly critical for anyone managing a health or pharmacy plan today. It’s easy to see why plan sponsors audit and monitor their claims continuoiusly.
