It's Time for a 100-Percent Audit of Your Self-Funded Plan

on May 21 at 05:05 PM
Along with technological advances in so many areas affecting businesses today, 100-percent audits of self-funded medical plan claim payments improve accuracy. Better methods for facility claims auditing are a multi-part process that begins with an electronic review. Today's better audits and continuous monitoring thoroughly report how a self-funded plan functions – including flagging claim payment errors of many types. It gives a company's in-house plan managers much-improved oversight of their third-party administrators (TPAs) and helps plans serve their members better.

More capable and sophisticated software continues to drive improvements in medical plan auditing. It's proprietary to the most effective auditing firms and adept at detecting even minor errors before compounding into more significant problems. The improved error-detection and reporting allow in-house managers to be more timely in their TPA oversight and manage their plans more effectively. Systemic improvements that can be made based on audit reports can quickly improve plan performance in lasting and essential ways. Following up with a continuous monitoring service helps ensure the intended error correction is accomplishing its goal and, if not, provides data for additional review.

The best audits cross-check carefully against a plan's unique provisions and documents. It brings in summary plan descriptions and all of their fine print, along with TPA agreements and employee benefits handbooks. Auditors checking against all of these are the ones who can review claim payments with the highest level of precision and accuracy. Drilling down to a fine level of detail reveals more about the TPAs' work and the plan's functioning. The old random-sample audits could easily miss details and provided far less transparency about each claim paid. Checking 100-percent of claims is always better.

Going a step beyond gathering the claim payment performance data is reporting it in an easy-to-read and actionable way. The best auditors understand that clear and helpful reporting is a crucial part of their role, and they take it seriously. Adding a layer of human review to the claims flagged electronically also speeds up the process. It allows software refinements that improve the audit's efficiency underway and future ones covering the same plan. Continuous improvements and advances in audit and monitoring processes have led to significant accuracy gains during the past 20 years.

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