Most medical plan sponsors understand the value of healthcare audit services in terms of cost savings and improved member service. It's also reasonable to recognize that continuous monitoring using the same audit software offers similar potential benefits. With claims processing typically outsourced, conducting audits is the best defense against costly errors and overpayments. While TPAs and PBMs often make performance guarantees, relying on them to self-report without independent review carries obvious risks. Therefore, it's advisable to have a claim auditor doublecheck their work.
The game-changer in claim auditing accuracy has been the 100-percent method made possible by technological advances. Software improvements now enable quick review of all claims against hundreds, if not thousands, of checkpoints, resulting in data of unparalleled accuracy. These tools empower in-house staff to oversee claim administrators more effectively than ever before, allowing them to monitor performance guarantees and address expense trends in their early stages. Medical plans that undergo frequent audits or continuous monitoring have reported better management outcomes.
Real-time expense monitoring is crucial, given the significant impact that spikes in claim costs can have on balance sheets. Continuous monitoring services run audit software in the background at all times, providing monthly reports. The value of the mistakes it flags exceeds the cost of the service, making it budget-friendly. Upper management appreciates the data provided, as it allows them to explain costs to financial analysts and others more effectively. Engaging an independent claim audit firm specializing in the field and using proprietary software and methods to deliver high-quality results is essential.
After all, auditing is only as good as the data it generates. If you've been conducting audits solely to meet regulatory requirements, consider increasing the frequency of audits for both medical and pharmacy claims, at least annually. The sponsors of the best-managed plans view audits as their most effective means of management and oversight. Neglecting audits for too long can lead to a pile-up of mistakes and overpayments that are challenging to recover. Working in arrears often creates issues you don't face when working closer to real-time. It also helps keep budget overages more in check.
