Large corporate and nonprofit employers that self-fund their health plans often do so with the important objective of reducing costs. In the wake of the pandemic and the rapidly evolving healthcare landscape, it has become increasingly important for these employers to consider utilizing medical claim auditing services to maximize their savings. Engaging professional auditors to conduct a comprehensive review of all claims can provide valuable insights into processing errors, medical billing discrepancies, coding issues, and other inefficiencies that may impact their health plans’ financial performance.
Notably, many plan sponsors audit claims more routinely, recognizing the significant cost-saving potential and improvements in plan performance that can result. A well-executed audit typically begins with an initial meeting to establish specific goals and ensuring the accuracy and depth of the final audit report. This collaborative setup ensures the auditing firm thoroughly understands the plan’s provisions and can accurately reflect them in the claim review process. Verifying that external claims processors adhere to the plan’s provisions is crucial, as any discrepancies can have substantial financial implications.
In addition to identifying and rectifying claim processing errors, audits often present opportunities for financial recovery. By scrutinizing all claims and meticulously documenting errors, auditors can uncover numerous potential recoveries, aided by advancements in software and audit system technology that enable them to produce increasingly detailed and accurate reports. This continual enhancement in the electronic portion of claim reviews has set a new standard for accuracy and thoroughness, presenting employers with new opportunities to optimize their health plan expenditures.
When planning an audit, it is beneficial to interview multiple firms and consider their expertise in auditing and medical billing. The complexities of untangling claims processing and payment errors go beyond traditional financial knowledge, requiring a nuanced understanding of medical services billing. For instance, identifying unnecessary duplicate tests or services brings potential cost savings and helps prevent the recurrence of similar errors in the future. It demonstrates the significant value that a well-executed audit can bring to an employer seeking to optimize their health plan’s financial performance.
