Beyond Dawlish

Self-funded medical and pharmacy benefit plans have many good reasons to audit, given the financial exposure for their sponsors. It's why today's highly accurate healthcare auditing companies are in greater demand. Companies and large nonprofits were hit with extraordinary costs during the coronavirus pandemic, and reviewing claim payments makes sense. When you work with a medical claim auditing specialist, they'll bring expertise to evaluate your processors' performance. It takes auditing expertise combined with a knowledge of medical billing best practices to review claims.

Auditors take a thorough and detailed look at claim payments and procedures to ensure they are within the plan's covered services. They may also look at member and dependent eligibility for verification as part of an overall review. Self-funded plans have a significant interest in accuracy, and with most outsourcing their claim administration to third parties, oversight becomes crucial. The audit reports are a useful management tool in several ways and often lead to system improvements for the future.

Each audit should be custom designed because no two plans are alike. Getting it right with details matters because an incremental approach to overpayment recoveries adds to significant sums. Anyone who takes a one size fits all approach or has audit knowledge but needs more medical coding expertise may need to catch up. It's why exercising care when selecting an audit firm matters. People with the right technology and experience can make it appear easy, but the process is complex. Specialists who work in the field daily become familiar with most processors' systems and can audit them more effectively.

If you're managing a plan in-house and working with an outside processor, oversight can be challenging until you audit. Then you have a clear picture of your claim administration accuracy and can have meaningful conversations about opportunities for improvement. Many plans today opt for continuously monitoring their claim payments with monthly reporting from auditors. The service commonly saves much more than it costs and keeps claim processing on track. Given the relentless rise in medical and prescription costs, it's easy to understand why auditing and monitoring are gaining value to plans.