Overseeing employer-funded health plans' operations is crucial, as outsourced administrators handle millions of dollars in claims weekly. It is why plan sponsors frequently utilize medical claims auditing companies to scrutinize their payments. Throughout various times and challenges, claims audits have consistently demonstrated their worth—most recently highlighted during the coronavirus pandemic. As utilization and costs surged, plan sponsors relied on auditors to assess and report these activities. Today, many plans incorporate real-time auditing and monthly reporting to enhance their oversight.
Technological advancements have significantly refined the process of auditing healthcare claims, resulting in impressive accuracy today. Double-checking all claims dramatically increases the chances of uncovering every error. Unlike the old random sampling methods, where results can vary based on the sample chosen, the 100-percent audit approach ensures consistency. If any sections are reviewed again, they will correlate with the original findings. As monitoring and auditing efforts continue, all irregularities in claim payments are flagged and communicated, ideally soon after the fact.
For those working in-house at a benefits plan sponsor overseeing external contractors, there may be specific areas you want to investigate. Auditors can assist, and incorporating targeted questions during the audit setup meeting can ensure the final report addresses your concerns. Although current processing error rates are low, even minor repetitive errors can accumulate substantial costs. Well-managed plans ensure that every claim is processed correctly and that mistakes are rectified promptly. Collaboration with auditors allows for regular reporting, enabling you to request system improvements.
New motivations to audit claims have recently emerged, particularly concerning legal matters. Activist law firms are initiating class-action lawsuits for breaches of fiduciary responsibilities, while other sponsors find themselves taking legal action against their processors. It underscores the importance of maintaining oversight of your plan's claim payments and your processors’ peeformance. By promptly identifying mistakes, you can prevent them from escalating into more significant issues, making it easier to seek reimbursement for overpayments. There are numerous advantages to conducting audits.
