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montmcdonald.com Group

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Detail Orientation Makes Claim Audits Better


Today, it's widely understood in health plan management that a 100-percent healthcare audit offers superior accuracy compared to random sampling. This heightened precision allows for the identification of more errors, the discovery of additional overpayments, and the generation of more detailed reports. For plan sponsors, it presents an opportunity to oversee third-party administrators and pharmacy benefit managers more effectively. The increased audit accuracy makes it a more robust management tool, aiding plans in managing their claim costs - the processing function needs review. 


Advancements in the proprietary software used by specialized claim auditors have driven numerous improvements, enabling a more comprehensive review of details. The cost of the audit service is budget-friendly, as it can recover up to four times the price of the service. Those who have not experienced a 100-percent audit before will find it pleasantly surprising. The previous random sampling method was more time-consuming and less accurate. Today's audit software expedites the review of thousands of claims, producing precise, actionable data about TPAs and PBMs' work and accuracy. 


In addition to aiming for well-managed health and pharmacy benefit plans, sponsors must grapple with the continual rise in healthcare costs each year. Managing these costs while ensuring plan members receive excellent care is the objective, and audits provide insight into performance. Today, it's common for companies to run audit software continuously for real-time monitoring of claim payments. Detecting and rectifying errors in real-time is unparalleled, and it's easier to recover overpayments soon after they occur, as opposed to dealing with issues months or years later. It achieves fiduciary "best practices." 


Claim audits have evolved and improved since their origins as a compliance matter. Their efficiency and value to management have led to their more frequent use, and the value they produce is undeniable. Better technology also means reduced human involvement in the review process, which continues to improve yearly. Upper management with fiduciary responsibilities requires well-managed plans, and audits provide a means to achieve this. The presence of oversight naturally encourages TPAs and PBMs to work more carefully, and it confirms their performance guarantees.

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