Add Oversight to Self-Funded Health Plan Claim Processing

on May 08 at 01:13 PM
Health care costs in the United States rise every year, and the recent coronavirus pandemic added a significant new area of costs. It puts self-funded company plans under even more financial pressure, but medical claims auditing companies can help. Besides the mistakes and irregularities they flag during audits; continuous monitoring service can make a huge difference. It leverages the same audit software but puts it to use reviewing claims in real-time. Improved oversight puts in-house plan managers in a much stronger position to manage third-party claim administrators (TPAs).

Everyone whose job includes health plan management has heard horror stories about wild overcharges related to some coronavirus testing and treatment services. Self-funded plans with continuous monitoring already in place were on the lookout from day one to see if they were being hit with questionable billing amounts. Companies relying on after-the-fact audits will need to reanalyze and negotiate to recover overpayments or challenge out-of-line charges. Plan managers with real-time data were far more effective in managing the situation, serving their plan members, and controlling costs.

Audits of self-funded plans started out to be compliant with government regulations at the federal and sometimes the state level. But today, they have become more than a compliance issue. The significant sums of money spent on medical benefits and the potential for many overcharges and errors make auditing and monitoring essential. They have become strategic management tools that yield plan performance and cost savings benefits at the same time. Reviewing 100-percent of claim payments, which is the gold standard for accuracy, has ushered in a new era of audit accuracy and value.

Just as a technological advance has improved medical claim auditing and monitoring, it has brought enterprise-wide expectations for improved accuracy. Therefore, in-house plan managers face increased calls for oversight of TPAs, timely reports on claim payments, and thorough explanations for unexpected variances. All of these are helped by continuous monitoring or frequent audits where 100-percent of claims are reviewed. Because of the potential to prevent future mistakes and lead to the recovery of past overpayments, the cost for the audit and monitoring services are budget neutral or better nearly always.

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