The Best Claim Audits Review Every Detail

[TFGPartners]

Everyone knows auditing is a numbers game, but medical claim auditors double-check additional factors in the healthcare world. They look for coding errors, duplicate services, and other mistakes that add needless costs without improving member service. The game has changed since more powerful software ushered in an era of 100 percent reviews. It was a leap ahead from the days of random sampling when audits were general and not able to pinpoint every irregularity down to individual claims. Since the capabilities have improved, the price for the service has stayed below the errors it flags.

Drilling down into claim data requires sophisticated systems that can simultaneously check for many variables. It's one of the ways you can make a case for specialist claim auditors who focus all their efforts on the area. They are in the trenches daily, reviewing thousands of claims, and are well-positioned to discover new issues as soon as they arise. It gives you peace of mind about audit accuracy and their unvarnished report about your plan's performance. Claim audits are one of the best ways to determine a plan's financial health and member service success. They can focus on any factor you request.

Pharmacy claims have different variables from medical claims, but the opportunities from auditing are equally significant. Medications are famously expensive, and often manufacturers promise rebates and discounts – but are you receiving them? A pharmacy claim audit can give you answers and allow you to request any allowances that your plan is due but have not already been credited. The first time you audit and request corrections, how much was missed initially can be eye-opening. Given the number of claims and the need to combine them for qualifying discounts, it is a process ripe for mistakes.

No employer-sponsored benefit plans are alike, and auditors who take the time to understand your plan uniquely will produce more accurate reports. Pre-audit setup is a vital part of the process, and anyone who reviews your plan's claims in general terms will miss things. It's another thing in favor of firms known for meticulous work and ones that have only your plan's best interests in mind. Judgment calls must be made, and having a team that takes them seriously matters. You'll notice it in improved findings from your audit, and the suggested processing improvements add up over time.