Be State-of-the-Art with Claim Audits

Over the past two decades, medical claim auditors have made substantial advances, primarily driven by technological advancements. Enhanced systems and software have revolutionized an industry that once relied on random sampling, allowing auditors to now conduct thorough checks on every claim paid. The significant shift has increased the thoroughness and value of auditing processes, especially for large and medium-sized employer-funded plans. Today's audits deliver results with remarkable accuracy, identifying individual processing errors and overpayments with nearly perfect precision.

The appeal of contemporary claim audits extends to finance departments and C-suite executives, who appreciate these audits' greater accuracy and effectiveness. Proactive oversight offers essential peace of mind and helps fulfill fiduciary responsibilities for plans that would have otherwise faced informational gaps. It's critical to recognize that third-party processors often self-report, but the question remains: Are they capturing every relevant detail? Independent auditing firms, particularly boutique ones, tend to provide excellent oversight with audit and medical expertise.

Auditors focusing on tax and financial matters may lack the nuanced understanding required to navigate the complexities of medical billing. A comprehensive audit involves sifting through hundreds or even thousands of data points across numerous claims—a task only advanced systems can perform effectively. Continuous, hands-on experience in the field and consistent evaluations of the work done by large claim processors and administrators are irreplaceable. Moreover, the rapid evolution of medical treatments and medications adds another layer of complexity to claim auditing.

Relying on the same audit methodologies year after year is insufficient in a dynamic environment where practices are continually changing. As a result, auditors must consistently refine their approaches, ensuring their systems are equipped with the latest developments. There have been instances where auditors' findings have prompted claims processors to update their systems to prevent coding errors, which can lead to overcharges or duplicate billings. The capacity to scrutinize these issues individually significantly enhances the overall value of claim auditing for every self-funded plan.