Not long ago, many self-funded medical plans conducted claim audits to meet regulatory requirements, often relying on random samples. If these medical claim auditing practices had remained unchanged during the pandemic, there would have been less scrutiny of claim payments, given the incredibly challenging year for many organizations. Fortunately, medical bill reviews have advanced, with many auditors now reviewing 100 percent of claims rather than relying on random selections. The shift has resulted in more accurate audits, which plans recognize as essential strategic management tools.
Audits that started to ensure compliance have evolved into a critical oversight mechanism that in-house plan managers now regard as indispensable. The advancement in auditing software has enabled these thorough 100 percent audits, which have led to asset recoveries that significantly outweigh the cost of the audits themselves. This process guarantees members receive fair treatment and strengthens the position of in-house staff in discussions with third-party administrators (TPAs). Since TPAs frequently offer accuracy guarantees, having an oversight process in place is vital for confirming their performance.
The emergence of firms specializing solely in medical and benefit claim reviews has further elevated the auditing process, leading to enhanced accuracy and insight. Many of these firms have seasoned professionals who formerly worked with major health carriers. The accumulation of expertise has been harnessed to refine audit processes, resulting in methods and technologies that provide plans with unparalleled accuracy. Additionally, this comprehensive approach equips these plans with an added layer of protection against potential fraud and abuse, as audits thoroughly evaluate all claims.
Many large employers, whether corporate or nonprofit, have recognized the value of more accurate audits, prompting a growing trend toward continuous monitoring. This cutting-edge service utilizes the same software, but it provides ongoing updates. Should there be unexpected increases or trends in claims, the data generated allows for quicker responses. For corporations facing the pressure of quarterly earnings reports that are affected by rising expenses, having detailed data is essential for providing thorough explanations. Ongoing monitoring improves health benefit plan management.
