Post-Pandemic, Health Plans Deserve Review
Like every type of health insurance, employer-sponsored plans took a beating during the pandemic. Given that experience, now is the time for medical claim audits to help assess the best path for the future. It's routine for claim administrators, often large health plans themselves, to report data to sponsors. But an independent review from an outside audit firm continues to make sense. Their analysis gives insight into claim expense and notes any irregularities. The recovery possibility exists for all errors flagged, but often the more significant opportunity is system adjustments to make claim payments more accurate.
Any resistance to claims audits usually goes away when it becomes clear they create savings and add dollars to the bottom line (not expenses). It's rare for a service to generate income, but they do in the form of recoveries. Also, preventing future mistakes adds to the bottom line. There are many value additions from health plan auditing, and member service can also benefit. For public companies reporting quarterly earnings, unexpected medical and prescription cost overages can affect the bottom line. Audits can untangle what happened and confirm the accuracy of information provided by others.
It's always wise to ask about their methods and processes when interviewing auditors. For example, their pre-audit setup is a topic to bring up. An audit's success has much to do with its setup, especially in uncovering previously overlooked mistakes. Ensuring your plan's provisions are noted and entered correctly matters significantly. Using a general formula will flag easily detected items but may miss those buried deeper. Often, the more significant financial recovery opportunities lie in previously undiscovered things. Most claim processors self-audit and report their findings, but are they right?
Oversight is crucial for all claim payment administration because there are hundreds of variables on each claim, and thousands are paid. The complexity of medical coding and billing also adds potential for errors. With pharmacy claims, formularies, and other provisions being detailed and ensuring the proper medications in each category are dispensed is crucial – it affects costs profoundly if opportunities to provide generics are missed. Even when providers and claim administrators act in good faith, the knowledge that plan sponsors routinely conduct oversight matters. It helps keep things on track.
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