Health Plans: Keep an Eye on Claim Payments

You're likely familiar with medical claim audits if you're working in-house at a large company or nonprofit managing an employer-funded health plan. But how would you feel if someone suggested a healthcare auditing company conduct monthly claim reviews? If you're hesitant about continuous payment monitoring, health plan challenges may change your perspective. Plans that implement active payment monitoring can benefit from real-time oversight of their expenses. We've all heard stories of outrageous overcharges and escalating costs affecting health plan budgets.

Human nature tends to be cautious when there's oversight, and frequent claim auditing has a noticeable impact. Correcting errors and overcharges can be laborious and expensive, leading providers to prefer avoiding issues altogether. Once it becomes clear that follow-ups regarding mistakes will occur, they will likely take greater care, which helps uphold fiduciary best practices by ensuring accurate claim payments. This proactive approach reduces potential legal risks and aligns with regulatory standards. Also, accurate claim payments enhance the experience for members, ensuring fair treatment for all.

Considering the advancements in claim reviews today, the progress from the past is remarkable. The shift from random sampling to comprehensive reviews has changed the auditing landscape. Today, it's standard to identify and flag errors individually, and the results remain consistent if the same claims undergo multiple reviews. This consistency contrasts with random sampling, which varies depending on the chosen claims. Consequently, many plan sponsors now view auditing as a crucial management function rather than just a compliance issue, recognizing the benefits of verifying payments.

Medical billing undergoes annual changes as new treatments, services, and medications enter the market. While claim administrators strive to stay on top of these changes, some will inevitably slip through the cracks. It is where auditors become a vital second line of defense. Partnering with a firm that reviews claims across various plans allows you to benefit from their extensive experience, providing insights that can prevent overpayments when errors are identified, which can then be addressed for reimbursement. Speaking up during pre-audit meetings is essential to clarify your plan's provisions.