Optimize to Run Better Claim Audits

Posted on 29 July, 2024 by TFG Partners, LLC

Companies that handle medical and pharmacy claim processing for employer self-funded plans must undergo periodic audits, ensuring regulatory compliance and financial oversight. Medical claims auditing is becoming increasingly frequent each year and is vital for overseeing the complex process of medical claims payment. The value of medical claims auditing is particularly significant for larger plans, where the impact of inaccuracies can be substantial. Doublechecking coding accuracy is a critical aspect of claim audits, as it directly affects a plan's costs and providers' revenue—correctness helps everyone.

Accuracy is paramount, so audit firms must ensure that any claim processing system is accurate, reducing time and expenses for all involved parties. The necessity of oversight in such a complex process explains the growing frequency of audits. The latest development is the introduction of continuous monitoring services, which provide monthly reports on claim payments. This proactive approach presents a significant benefit to self-funded plans, helping keep claim payments on track and enabling increased scrutiny, especially during unexpected events such as the coronavirus pandemic. 

Identifying and recovering funds from overpayments presents substantial financial opportunities for self-funded plans. Early detection through audits makes recovery more accessible and more effective, underscored by the significance of frequent auditing and monitoring. For-profit corporations self-funding their benefit plans are susceptible to claim costs impacting their bottom line. Therefore, having accurate data available is crucial to confirm the general accuracy of claim payment operations and fulfill fiduciary responsibilities to ensure that expenditures benefit plan members. 

Incorporating technology into claim audits has achieved significant accuracy gains over the past two decades. Software advancements have fine-tuned capabilities to review claim payment details at a granular level, offering near-miraculous improvements over the earlier days of random sample auditing. Although human oversight continues to play a role, it now involves reviewing the results of electronic sweeps. Today's systems audit faster and require less time and human intervention than earlier versions, resulting in a win-win situation for all stakeholders involved.