Claim Auditing Checks Health Care Cost Increases

Self-funded health plans have faced financial challenges for years due to soaring medical expenses, and the COVID-19 pandemic has further exacerbated these pressures. This backdrop has led to a surge in demand for healthcare auditing companies, which assist in-house plan managers in sifting through many claims to identify errors and discrepancies. Implementing sound plan management practices necessitates oversight, regardless of claim administrators' assurances regarding their accuracy. As the volume of claims processed increases, so does the potential for mistakes.

The most effective method for auditing a medical or other benefit plan is to examine 100% of paid claims. This approach is an advancement over traditional random sampling techniques. By reviewing every claim electronically, with human verification for flagged issues, organizations can better understand their claim payments. Errors often recur, and spotting them early makes it easier to address the underlying problems. Today, savvy companies conduct audits more frequently than what ERISA or Sarbanes-Oxley mandates to ensure their plans operate optimally.

A comprehensive audit involving 100% of claims is a foundational step, followed by detailed analysis, recovery efforts, and critical recommendations for system enhancements. Effective claim auditing leads to better-functioning plans, with many organizations now opting for continuous monitoring services. It monitors claims processing in real-time and allows for immediate reporting of errors. The popularity of this service is evident, as it proves to be a valuable management tool. With weekly performance reports, businesses can avoid unexpected surprises.

Informing your claim administrator about advanced oversight measures improves accuracy. It enables data-driven discussions in meetings, facilitates problem-solving, and ensures your company's benefit plans remain on track. When faced with sudden cost increases, you can analyze them efficiently and communicate any budget implications to upper management. This proactive approach contrasts with a passive stance where claim payments spike unexpectedly, leaving you with little insight into the causes. Additionally, it ensures that mistakes are addressed promptly, preventing them from accumulating.