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You're familiar with medical claim audits if you're in-house at a large company or nonprofit overseeing an employer-funded health plan. But what if someone suggested having auditors review your claims monthly? How would you react? If you are skeptical about the continuous monitoring of payments, the recent coronavirus pandemic might put it to rest. Plans with active payment monitoring in place had a real-time double-check on their expenses during an unanticipated period. Everyone has heard the stories about wild overcharges and skyrocketing costs affecting expenses. It's human nature to be careful when it's known others are paying attention, and frequent claim auditing affects medical and pharmacy providers. Correcting errors and overcharges is time-consuming and costly; they'd rather avoid it. Once it's known that you will follow up about mistakes, greater care will be taken to prevent them. It also contributes to fiduciary best practices when your claims are paid accurately. It can prevent you from legal exposure and meets regulatory requirements. Accurate claim payments also serve members better, as all are treated equally. When you consider the state of the art in claim reviews today, it's impressive compared to where things started. When 100 percent reviews replaced random sampling, the game changed quickly. Now, it's common to find every error and flag it individually. Also, the findings would be consistent if the same claims were reviewed twice. Random sampling would change every time depending on the batch of claims reviewed. It's easy to see why plan sponsors today regard auditing as a management function more than a regulatory and compliance issue. They gain much from double-checking payments. Medical billing changes every year with new treatments, services, and medicines coming on the market. Claim administrators are on top of many changes, but some are bound to fall through the cracks, and when they do, auditors provide a second line of defense. When you work with a firm reviewing claims from many plans, they arrive with experience that benefits you. It's valuable insight you might not have otherwise and keeps you from overpaying when errors are caught, and you can request reimbursement. Remember to speak up during the pre-audit meeting about your plan's provisions.
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