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Claim Audits Stop Million-Dollar Problems?


Medical claims auditing is critical in ensuring the integrity of benefit plans offered by large employers, spanning both corporate and nonprofit entities. The potential financial impact of erroneous claims payments, which can run into hundreds of thousands or even millions of dollars, underscores the necessity of conducting regular reviews. Attentive scrutiny of medical claims and thorough evaluation of pharmacy benefit plans form a reasonable and prudent approach. The resulting recoveries often far exceed the initial investment in conducting the audits, sometimes yielding up to four times the cost.


The presence of team members with an intricate understanding of claim payments from large health carriers is a valuable asset. While large audit firms prioritize other matters, recent strides made by smaller firms have brought about transformative changes. Notably, the development of software enabling a comprehensive 100% review of claims has abolished the need for random sampling and manual verifications, significantly enhancing the audit process. Comprehensive audits are designed to flag all errors, with the focus contingent on whether a payer or provider sponsors the review.


Payers are vested in finding inaccuracies, overbilling, duplicative charges, and recurring error patterns. Meanwhile, providers prioritize ensuring the precision of codes entered and services billed. Accurate payments benefit members, providers, and plan sponsors. Sometimes, companies extend their vigilance to continuously monitor claim payments to ensure prompt error identification and reporting. The rise in the utilization of audits within self-funded benefit plans parallels the shift towards outsourcing claim administration.


Although performance guarantees are typically included in processing service agreements, regular oversight is essential to validate adherence. Given the potential financial implications of claims, sponsors are compelled to closely monitor payment activities and uphold the highest standard of accuracy. Numerous checkpoints are reviewed through meticulous examination of each claim, effectively averting the escalation of issues into substantial financial liabilities. In essence, conducting audits is an indispensable and effective tool for managing the costs of benefit plans.

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