When large employers self-fund their benefits plans, including medical and prescription coverage, they commonly outsource the claim processing. Scheduling a healthcare claims audit to see if the error rate is within the promised one to three percent is standard. The audit report can be highly accurate if 100 percent of claims are reviewed and provides an objective review of cash...

In an oversight situation like medical claims auditing, independence means a lot. If you're working for a plan sponsor and need to double-check your outsourced claims processor, finding a specialist audit firm that's entirely independent can be your best bet. They have no other interest than seeing your plan do its best. Given the overpayment recovery possibilities of a thorough audit, it's...

Not all medical claim auditors are alike, and if you're a large employer sponsoring your company's health plan, you want the most accurate firm. The best claim auditors have perfected proprietary software that powers their audits. All audits are about getting the details right and scrutinizing every data point on every claim. When electronic reviews are highly accurate, it saves time and money,...

Bigger isn't always better, and when it comes to medical claims auditing, smaller, independent firms are often the best. It's because some firms specialize in claim audits and do nothing else. Their total focus on claim reviews gives them particular expertise that's tough for larger firms to match. Many count executives with prior health plan experience among their management, providing them...

How often should benefit plan claims be audited is a common question among those responsible for managing plans, especially self-funded ones. It varies because no two plans are alike, but medical claims auditing is in increasing demand, and audits are occurring more frequently. It's likely because sponsors have realized the value in running oversight, especially as most have outsourced the...

The trend for many years among larger employer-funded benefit plans has been to outsource claim processing. Large insurance carriers handle it with sophisticated capabilities amid promises of cost savings excellent results. But only a healthcare claims audit can verify if the commitments are being met and every opportunity for efficiencies leveraged. The third-party administrators providing the...

In the wake of the coronavirus pandemic, auditing claims – both medical and pharmacy – continues to be a much-discussed topic. The COVID-related spike in costs was historical for some plans as new tests and services came onto the market at wildly varying costs. Depending on where a plan member sought services, the price billed for like items could be vastly different. Audits have...

The oversight function of auditing is crucial to anything involving financial transactions, including health and pharmacy benefit plans. Their claim payments are a significant financial exposure for the plan sponsors, and keeping tabs on them is needed. As a result, medical claims auditing has a considerable role in good plan management, balanced service to members, and cost control. Auditors...

Many health plan sponsors might not have thought much about oversight in the early days of outsourcing their claim processing to third-party administrators (TPAs). Sponsors used health plan auditing services more for regulatory compliance than anything else. But as those audits have improved in accuracy over time, it has become clear they are valuable management tools. Letting TPAs and pharmacy...

A few people still working in medical and pharmacy claims management may recall when audits were more to meet regulatory requirements. But everyone who has joined the field recently knows pharmacy, and medical claims auditing is an excellent management tool. The method and technology have been improved continuously through the years. Today, they have an impressive level of accuracy that makes...