With each passing year, deeper experience is gained in benefit claims auditing, consistently proving that reviewing payments soon after they occur is beneficial. A health plan and PBM audit today employs advanced software and specialized expertise. The outcomes of their reviews frequently exceed those of larger, more generalist firms. Their focused skill set enables them to identify where errors can occur, uncover them, and provide actionable reporting. Consequently, they are far more effective at catching patterns of mistakes and advising plans on recovery strategies.
Employer-funded plans that use third-party administrators and pharmacy benefit managers give outside parties control over payments. This is a major responsibility, and large health carriers fulfill it by offering networks and negotiated pricing to plan sponsors. Each has processes for paying claims based on set criteria. However, many employer plans differ from carrier rules and need more tailored claim payment and processing. These differences are often where issues arise—and where auditors can discover errors. It’s also why implementation auditing at 90 days is vital after the switch to a new claim administrator.
Letting mistakes linger for months or years, then trying to recover overpayments or fix past errors, is much more difficult. Experts recommend frequent or continuous audits using specialized software. Both methods catch errors in real time, making fund recovery more straightforward. Trying to piece together events from long ago is far harder and can interrupt provider cash flow when refunds are needed. Addressing errors close to when they happen makes recoveries quicker and negotiations smoother. Working longer in arrears often complicates recoveries.
Modern claim audits now routinely review nearly all claims paid. Those who suggest skipping full reviews may lack advanced auditing technology. The power of current software lies in its speed and accuracy, quickly producing results that are close to final. Skilled auditors can promptly assess these findings without burdening client staff. Detailed, yet streamlined, audit reports are also increasingly common. When information is presented clearly, it’s easier for decision makers to respond promptly. Specialist claim auditors work like management consultants, helping employer plans improve.
Top comments (0)