The Improved Value of Today's Medical Claim Audits

on June 03 at 09:40 AM
The never-ending charge of technological advances has changed and disrupted many paradigms in recent years. In the world of corporate benefits management, medical claim auditing has benefitted mightily from more sophisticated software. It is now routine to review 100-percent of claims during an audit which is far more accurate than a random sample. Companies and nonprofit employers with large self-funded plans are taking advantage of the improvements. Many add claim payment monitoring services to continue the audit in real-time. The benefits are apparent when every payment is double-checked.

As more and more self-funded plans outsource their claim payments to third-party administrators (TPAs), additional tools like claim payment monitoring are needed to manage them closely. Because TPAs are large health plans customarily, they may have promised a high level of payment accuracy to earn your processing contract. But are they doing as well as promised? The only way to know concretely is to audit and monitor their work. It facilitates concrete discussions between your in-house staff and people at the TPA. If your claim payments rise quickly, you can check the data to see what is happening.

When costs go up, it is sometimes difficult to know the cause because many factors go into the equation. It's why reviewing 100-percent of claims using today's best software technology lets you see what's happening more clearly than ever before. The financial exposure on self-funded medical and pharmacy benefit plans is enormous, and they can affect quarterly earnings reports that drive stock prices. When unexpected events like the recent coronavirus pandemic arise suddenly, having a well-managed plan means everything. Claim payment accuracy also helps members with high deductibles.

The trend toward monitoring payments continuously has been sparked by its relatively low cost compared to the payment errors it helps recover. It was common for payment errors to continue undetected in the old days until they were numerous and amounting to significant sums. Now it is routine to catch them early and make system improvements that eliminate them for the future. It is also helpful in keeping claim payments in line with plan descriptions and promised benefits. Every plan has its complexities and making sure they are followed helps keep claim payments on budget.

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