The Claim Auditing of Self-Funded Medical Plans
Large employers, corporate and nonprofit, with self-funded medical plans have a lot on the line. As the recent coronavirus pandemic showed, unexpected events can lead to sudden cost increases. It is why medical bill auditing services are more in demand than ever before as plans try to sort out their recent claim expenses. Auditing the past year's claim payments is the only way to understand concretely what was paid and if there were patterns of fraud and abuse. There have been many stories of unscrupulous people trying to use the pandemic as cover for their fraudulent activities, and plans need to stop them.
Auditors today have the most sophisticated claim review software ever, and they can scrutinize 100-percent of claims payments with remarkable accuracy. With skyrocketing costs, this is no time for the old random sample methods. It's a moment to crack down on fraud and abuse with concrete, actionable audit data. Plan managers give their executives more detail and peace of mind about health claim expenses as they audit frequently and with excellent accuracy. Much of what can be done today would have been unimaginable even 20 years ago. Today's claim auditing reviews every payment accurately.
Executives with experience at major health carriers have increasingly joined audit firms and brought their knowledge with them. It has led to significant advances that have costs plans nothing because nearly always audits recover more overpayments than their cost. Most self-funded plans have outsourced their claim payments to third-party administrators (TPAs), often large health plans. While their processing and payment operations are sophisticated, it's still possible for mistakes to happen and some questionable payments to slip through the cracks. Audits flag them and save plans money.
In-house plan managers need concrete data for meeting with TPAs about claim processing accuracy, and audits provide it. A new trend for plans is to use the same audit software for continuous monitoring. It is ushering in a new era of accuracy and catches mistakes and irregularities while still small and easier to solve. Also, when overpayments occur, it's much easier to recover them quickly than to wait one or two years and follow up to correct them. Plan members with high-deductible coverage also benefit from more accurate claim payments. So there is a member service improvement as well.
