Employers sponsor benefit plans to do the right thing for their employees and remain competitive in the recruiting marketplace. But the plans are expensive and must be managed closely. Medical claim auditing services are one way to conduct needed oversight, and the same applies to pharmacy benefit plans. Double-checking claim payments customarily adds to your bottom line rather than subtracting. That’s because today’s claim audits check every payment and are increasingly accurate. They’re left in the dust if you have been around long enough to recall the random sampling days.
What is most interesting about benefit claim auditing is the chance to pose virtually any question about your costs and experience and have it answered. Reporting from outsourced claim administrators is similar, but they would be using the same system to detect errors that were made initially. Independent auditors use their systems to check the payment processing and can find things others may miss; while they are at it, you’ll be taking care of regulatory and compliance-related audit requirements. Once you see the results, you may keep the auditors around continuously to watch your payments.
If your plan needs a tune-up and you’re in conversations with your claim administrator, consider running an audit. It’s an excellent way to gather data and pinpoint the areas with the most significant opportunity for improvement. For example, if you have been paying for overlapping or duplicate services because care coordination has been lacking, the results from an independent claims review can be helpful. Factual data allows you to have a more focused negotiation than relying on less precise information. Medical claims are a detailed sector; making improvements means getting them all handled correctly.
Working with auditors who handle many plans can give you insight into your performance versus industry standards. Claim administrators and pharmacy benefit managers are the same, but the auditors are independent and have nothing but your plan’s best interests at heart. They can check against your plan’s provisions and compare them with industry standards. It’s one way to ensure your claims are paid with “best practices” that benefit members and help contain costs. There’s a trend to audit more frequently and monitor continuously for all these reasons.