Large employers self-funding their benefit plans do so in an era of never-ending change. It affects health plans most significantly, and healthcare auditing companies are essential to oversight and management. With nearly all claim administration outsourced today, an independent claim audit is the only way to have a second opinion on accuracy and performance. Auditors can be your plan's advocate if third-party administrators or pharmacy benefit managers make errors. Most have impressively low error rates and often guarantee their performance.
But if you rely on their self-reporting, can you be entirely sure? Speaking of change, switching to a new processor is another moment for an audit. Doublechecking your plan's claim payments after 90 days with an implementation audit is an excellent idea. An independent analysis of your administrator's self-reporting will also prove enlightening. If it lines up closely with the auditor's report, that's excellent news. But if there are discrepancies, you can get things fixed before issues multiply into more significant problems. It's also why more plans than ever have their claims reviewed continuously. Monitoring service with monthly reporting keeps you informed in real-time.
If the COVID-19 pandemic taught health plan sponsors anything, it was the need to have a strong management and oversight infrastructure in place. Plans that were loosely managed fared poorly compared to their tightly managed counterparts. Having auditors in place is an excellent way to support fiduciary best practices and manage your plan well. Knowledge is power, and nothing replaces factual data in the benefit claim arena. Trying to manage an outside vendor only works when you have independent oversight. Going into meetings well-informed and knowing the facts is a game changer.
As you interview claims auditors, if you're handling it for your company and health plans, keep specialization in mind. Auditors who bring specific knowledge of medical billing to the table will often be able to help the most. They know what to look for and understand other concepts, such as coding and duplicate services. When those checks are built into audits with a deeper understanding, the value of the data gathered and reporting is generally more robust. The value of audits often comes down to the details, and specialization helps. It also comes through in the reporting, which is of greater value.
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