Large employers spend millions of dollars monthly on health care for their employees. Their self-funded plans can benefit from medical claim auditing to improve performance. A rudimentary audit will flag errors and irregularities, many of them recoverable. However, a sophisticated claim review will check every payment against the plan's provisions, reasonable and customary fees, and other variables. Our of these thorough audits come suggestions for how plans can improve their performance to serve members while controlling costs. Thousands of variables can affect expenses monthly.
Digging down to a fine level of detail in a claim audit requires advanced systems and an understanding of medical and pharmacy billing, two complex topics. The more an audit firm understands your plan's provisions and can compare them against claims paid, the more it matters. Therefore, audit setup is crucial and affects the reported data value. There are no shortcuts to an accurate audit; you want people devoted to accuracy and detail orientation. When every claim is reviewed, it becomes possible to find all errors. As the plan sponsor, you can then determine which ones are worth requesting for recovery.
Given the quality of data produced today by electronic reviews, the time it takes to produce the final, highly accurate results is reduced. It leaves more time for analysis and system assessment. There may be numerous improvements that will tighten up processing and save considerable sums over the long term. Members are also served more equitably, and your plan's fiduciary responsibilities are better met when claims are paid accurately. It's also beneficial when the same firm reviews your payments and can compare periods. Then, a more accurate picture emerges.
With claim payments nearly universally outsourced today, oversight has become more necessary. Also, if audits are to produce savings consistently, they need to become more sophisticated. As administrators drive error rates lower each year, the remaining mistakes are more minor and buried deeper. Auditors with powerful systems and years of expertise are the only ones equipped to dig deeper and find the remaining errors and irregularities. Their technologically advanced systems are up to the task, and the ones who work in the field know best daily. Also, healthcare billing changes and evolves each year.
This performance improvement policy template outlines the process for improving performance, addressing performance discrepancies from an appraisal and for performance management.
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