Last Updated:
April 29, 2024

Posts tagged "medical benefits plan auditing"
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Minor Errors Add Up in Claim Payments

Every medical claim paid is a complex endeavor. One way for employer-funded plans to police the accuracy of their payments is a healthcare audit. Reviewing each payment made by a third-party administrator or pharmacy benefits manager is a crucial oversight function. Catching and correcting significant error patterns is vital, but so is finding individual mistakes. Taken together, minor errors add up to substantial sums for many plans, and flagging and correcting them makes a difference. It supports cost containment efforts and improves member service when claims are paid correctly with consistency. The audit setup is one of the most crucial parts of the process because everything flows from it. A one-size-fits-all approach won’t yield the benefits of a customized configuration. The nuances of each plan need to be addressed by the audit software, ideally by someone with equal expertise in medical claims and audit techniques. It’s why all claim auditors aren’t alike, and selecting the best makes a difference. They bring years of expertise and a specialized approach that adds value. There is no substitute for working in the field daily, staying current with trends, and continuously improving. As claim audit technology and systems become more sophisticated, the electronic portion of […] read more
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Minor Errors Add Up in Claim Payments

Every medical claim paid is a complex endeavor. One way for employer-funded plans to police the accuracy of their payments is a healthcare audit. Reviewing each payment made by a third-party administrator or pharmacy benefits manager is a crucial oversight function. Catching and correcting significant error patterns is vital, but so is finding individual mistakes. Taken together, minor errors add up to substantial sums for many plans, and flagging and correcting them makes a difference. It supports cost containment efforts and improves member service when claims are paid correctly with consistency.   The audit setup is one of the most crucial parts of the process because everything flows from it. A one-size-fits-all approach won’t yield the benefits of a customized configuration. The nuances of each plan need to be addressed by the audit software, ideally by someone with equal expertise in medical claims and audit techniques. It’s why all claim auditors aren’t alike, and selecting the best makes a difference. They bring years of expertise and a specialized approach that adds value. There is no substitute for working in the field daily, staying current with trends, and continuously improving.   As claim audit technology and systems become more sophisticated, the […] read more
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Claim Auditing is a Plan Management Tool

Managing health and pharmacy benefit plans carefully is a requirement for large employers that self-fund them. The costs are high, and with prices constantly rising, a medical insurance audit is one way to double-check the accuracy of claim payments. Audits today check 100 percent of claims and involve less human participation. Specialist claim auditors with advanced proprietary software have become the leaders in the field, with more advanced each year. For health plan sponsors looking to confirm the reports received from third-party claim administrators and pharmacy benefit managers, they help. Prominent claim processors, often large health insurance carriers, have proven their value to self-funded plans by bringing their provider networks, negotiated rates, and advanced systems. But even they can miss an overcharge or occasionally make an error. While their service agreements may include self-auditing, only an independent review by an outside audit firm can confirm the accuracy. Oversight is a routine part of the system, and plans using it more often tend to be better managed. It’s now common to monitor claim payments continuously with audit software running in the background at all times. Replacing random samples with 100 percent reviews has improved claim auditing accuracy. It catches repeating error patterns and […] read more
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Claim Auditing Takes on a New Importance

What can an employer-funded health plan do best in the face of skyrocketing costs and extraordinary events (the coronavirus pandemic)? Several things exist, but reviewing claim payments should be near the top. Medical claim audits are an excellent plan management tool for many reasons. They provide oversight of third-party administrators, find and flag irregularities, and help ensure claims are paid consistently and correctly. Numerous financial and plan management benefits occur in the short and long term. Finding mistakes before they are million-dollar problems always helps. Most specialist claim audit firms today double-check 100 percent of claims and review them from every possible angle. The power of its software and methods is unrivaled, and it has a system to overview a claim administrator’s process. The biggest and easiest fixes are systemic improvements that prevent future errors. But today is also common for individual issues to be flagged that are well suited to recovery, which includes overpayments of payment in error. Plans emerge from an audit much better, and typically the price for the service is much less than the recoverable errors it finds and reports. Today’s claim audits also produce reports that are actionable and easy to understand. Compared to the […] read more
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