Beyond Dawlish

Watching payments continuously is one of the newest trends in medical claim audits. It allows plan sponsors (large corporate and nonprofit employers self-funding their benefit plans) to keep closer tabs on their cash outflow. Benefit claim administration established a scenario where one company can access another organization's checkbook. It creates one of the most clearcut needs for oversight in the business world today and is one reason auditing or monitoring the payments in real-time has become so popular. High-quality claim auditors find mistakes with values much higher than their service fees.

Today's electronic portion of claims reviews is more advanced than even a few years ago. It must evolve and become more sophisticated to keep up with changes in medical billing. As everyone's systems become more elaborate, audits must be able to cast a wide net to review the payments. Knowing medical billing and coding is a must, along with the financial side of auditing. Anyone trying to set up a claim review without substantial medical billing knowledge is bound to miss things. The deeper an auditor's understanding, the more performance improves – it's a game of details and precision.

The coronavirus was an eye-opener for many plans that had become complacent about reviewing their claims. When utilization rates skyrocketed, and new tests and treatments were rushed through the approval process, things went up for grabs. They've returned to more normal times now, but the need to be prepared for a future pandemic is now apparent in everyone's mind. It's created a sense of urgency to tighten oversight and plan management. Even when error rates stay low, the strain of a sudden, unexpected event is evident. No one's budget should be left exposed to a significant hit.

Most medical claims auditors encourage clients to include pharmacy benefit plans in their reviews. Although pharmacy benefit plans require different review criteria than medical claims, they are equally important. With thousands of prescriptions filled daily, there are opportunities for errors. They might be as simple as a name-brand product dispensed when generics are available or as complicated as an uncredited rebate covering thousands of patients. Because pharmaceutical pricing increasingly relies on price agreements, an auditor double-check is essential. You'll see savings every time you review claims.