Audit Benefit Claims to Control Costs

Medical and prescription costs have steadily increased despite numerous attempts to manage them. The coronavirus pandemic has further exacerbated this issue, leading to unprecedented spikes in utilization. These factors and general inflation intensify the usual rise in medical expenses. As a result, the need for health plan and Rx audit has never been greater. Thoroughly reviewing claim payments is an effective way to gain insight into spending and identify recoverable overpayments and errors. The independent, third-party review provided by an experienced auditor is excellent oversight.

Large employer plans have significant sums at stake, so finding substantial savings is crucial for the bottom line. It’s clear that oversight holds immense value. In many cases, claims audits recover four times their cost, making them budget-friendly with a considerable return on investment. Post-COVID, more plans opt for continuous monitoring by auditors to oversee claims payments. This ongoing service operates on the same systems and software as the initial audit, ensuring accuracy. Imagine receiving a monthly report that clearly outlines any irregularities in claim payments. 

Having real-time, high-quality information is invaluable. Specialist claim auditors have a proven track record of suggesting systemic improvements in claims administration. These adjustments can lead to significant savings over time without adding costs to the service, providing natural oversight for third-party administrators and pharmacy benefit managers. As audit firms establish long-term partnerships with clients, they bring added value in various ways, and the experience gained from auditing claims over multiple years is irreplaceable. You then can make apples-to-apples comparisons.

It’s important to note that today’s audits differ fundamentally from random sampling methods. Advances in technology and electronic reviews have made the auditing process faster and more efficient. Consequently, claims auditing is evolving into a management consulting role rather than just a regulatory compliance function. C-suite executives must present accurate information about factors influencing the balance sheet during quarterly earnings reports, and medical claim costs are a crucial element. Having reliable data on claim payments and associated expenses helps everyone involved.