Offering employees medical coverage is often the most fundamental part of benefits packages. As a result,medical claims auditinghas a significant role in managing costs and serving members well. There's no disputing that third-party administrators pay claims highly accurately today, but there's always room for improvement. Claim auditors are independent outside firms with proprietary systems and software that take an unbiased look. They flag errors and suggest system fixes that instantly save or recover thousands of dollars. When they are prevented from happening again, it s a boon.

When medical claim audits prove especially beneficial, it suggests the value of continuous monitoring. It keeps the software running throughout the year and makes monthly reporting possible. One of the great advantages is the ability to spot cost trends, either up or down, and analyze their origins. Understanding how they can add up to big savings and management improvements is a small leap. Auditing pharmacy benefit plans is equally beneficial; and can bring similar savings. It takes particular expertise to audit either, and finding a firm with the needed expertise is imperative; they are specialist auditors.

The audit's setup, in other words, the questions it will answer and the areas it will analyze, is crucial. When the setup is done well, the value of the audit and its findings increase exponentially. It's another reason why implementation auditing after the switch to a new claims processor is also vital. Doublechecking their work after three months either confirms accuracy or suggests areas for improvement. When mistakes are prevented from the get-go, it's easier for plan sponsors to stay on track financially. Mistakes nearly always add cost, and avoiding them has obvious benefits. If they are missed and multiple, it's an issue.

Every employer-funded medical plan has special provisions that need to be considered by outside claim processors and auditors reviewing their work. Understanding medical billing and claim payments down to a minute level is required. Generalist audit firms are primarily concerned with tax and finance issues and may have less medical billing expertise. Claims are paid based on hundreds of variables, and being able to tease out small mistakes requires a unique understanding. After you've had a highly accurate audit, it's an eye-opener about how much may have gone undetected.