Every Year, Claim Auditing Matters More
Cost management and delivering care to members are critical components of self-funded medical and pharmacy plans, requiring careful oversight to navigate thousands of variables involved in their administration effectively. One essential approach to achieving this is conducting Rx and medical claims auditing. Auditors with advanced software can deliver independent analysis that enhances oversight for third-party claim administrators and pharmacy benefit managers. While their systems are sophisticated and accurate, issues cannot easily slip through the cracks.
As claim auditing has gained prominence, it has become vital for plans relying on external administrators to manage their claims, often operating with an open checkbook approach. By auditing claims over successive quarters or years, organizations can identify trends, establish benchmarks, and pose meaningful questions that the audits can address. While self-reporting by claims processors holds some value, comparing their findings with those from independent audits provides a clearer and more informative picture. This ongoing analysis aids in managing costs and enhancing the quality of care.
You might be curious about the associated costs if you're contemplating more frequent use of claim auditing as a management strategy rather than merely a compliance measure. Reputable auditors frequently flag recoverable overpayments and other discrepancies that can amount to recoveries four times the cost of the audit. This positions auditing as a revenue-generating activity instead of a mere expense. As a result, many plans opt for continuous monitoring of their claims and receiving monthly activity reports from auditors. Fixing errors in real time is easier and more helpful.
Engaging in pre-audit meetings and interviewing audit firms can further enhance your understanding of claim auditing's value. Having factual data from audits is invaluable for in-house plan managers overseeing processors. The insights garnered serve as the foundation for negotiations and discussions with vendors, ensuring that you receive maximum value from their services. Moreover, conducting comprehensive reviews of 100 percent of claims, rather than relying on random sampling, significantly boosts the chances of recovering overpayments and correcting errors effectively.