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Insightful Claim Audit Results are the Norm


The best medical claim auditors put extra thought into their work and reporting their findings. When you audit payments for medical and pharmacy benefit plans, the results are nearly always enlightening. There's no doubt that claim administrators have sophisticated systems that drive error rates to low levels, but given healthcare costs, even a few mistakes are costly. There's also the responsibility for corporate and nonprofit employers, sponsoring their plans to run active oversight. It's part of fiduciary best practices and is required for legal compliance. Therefore, insightful audit reports are essential.


Claims audits today cover everything. It means that auditors review 100 percent of payments and double-check the medical and prescription medicine charges covered by the audit. There are countless opportunities to find savings, sometimes by recovering mistakes and other times for different reasons. When you work with an audit firm with deep medical billing expertise, they know where to look and can find issues like duplicate or overlapping services. When providers learn you question their charges, many become more careful with coordinating care for their members. It fosters accountability and more care in billing.


Audit setup is a vital part of the process and pivotal in determining the accuracy of the results. While much depends on the auditor's system, ensuring it is keyed to your plan's unique provisions means everything. The more the audit reflects your members, the services and medicines they have received, and the charges for them, the more valuable the findings. Any firm that takes a cookie-cutter approach is less likely to produce the most meaningful report for you. It also helps to have the same firm run successive audits. Then, you can compare reports to gauge each year's performance.


Some employer-funded plans have their auditors monitor continuously and report monthly. It adds excellent oversight and helps keep plans on track. Knowing about trending problems before they become significant issues is a great advantage. A perfect example of when this can work was the coronavirus pandemic. Plans with little to no active oversight were exposed to massive, unexpected costs. The ones with monitoring in place were on top of overcharges and irregularities immediately and made much more progress in correcting errors and recovering overpayments.

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