Healthcare costs continue to rise, with self-funded employer plans to shoulder their share of the financial burden. To better understand the increases, sponsors can benefit significantly from healthcare audit services and the data they generate. While many organizations outsource their claims administration and receive standard reports from processors, adding an auditor injects an additional layer of oversight and reporting, offering valuable insights. Setting up an audit can incorporate various specific health plan provisions to ensure that these details are considered when claims are processed.
The value of oversight became acutely evident during the coronavirus pandemic. The unprecedented hospitalization surge and escalating costs created an urgent need for precise analysis. By reviewing claims from that period, organizations gained insight, highlighting the enormous budgetary impact on health plans. Technological advancements have significantly influenced the landscape of claim auditing. A breakthrough in this field was implementing 100 percent claim reviews, eliminating random sampling methods that had dominated for decades, thereby reducing human error.
Highly accurate 100-percent audits are faster and can scrutinize every claim, marking a shift towards greater accuracy. This evolution has been further necessitated by third-party processors, which now manage most claim administration, making strong oversight even more crucial for plan sponsors. The specific provisions of a health plan play a critical role in how claims are adjudicated. While some plans align closely with industry standards, others may vary significantly based on the employer or employee's needs, leading to different coverage levels for services, treatments, or medications.
Auditing can verify that these specific provisions are honored and ensure payments are processed correctly. If discrepancies are found, auditors can recommend system enhancements and identify areas for recovery. The results from these audits provide concrete evidence, leaving little room for doubt, and empower plan sponsors in negotiations, particularly when armed with clear and detailed reports. When claim reviews identify and flag errors that lead to financial recoveries, they more than pay for themselves. For most health plans, a claim audit is a revenue producer rather than an expense.
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