The financial stakes are substantial regarding claims within health plans, making healthcare audit services a priority for many plan sponsors. Regulations mandate that these plans operate in the best interests of their members, with accurate claims processing being a top priority. It is also a critical issue for large corporate and nonprofit employers who manage their own health plans. Over the past few years, budgets have been increasingly strained due to rising medical costs, and with no relief in sight, continuous reviews of all aspects of health plans are essential for effective management.

Experts agree that hiring an independent auditing firm offers benefits. While the capabilities of these firms are the most apparent advantages, impartiality is equally crucial. If in-house employees of the claims administrator conduct audits, biases may be present. An independent firm provides an unbiased assessment of plan performance, often revealing errors and inconsistencies that can be addressed. These audits may result in recovering overpayments or identifying claims for services not covered. Today's auditors electronically review 100 percent of claims, leading to accurate outcomes.

It's uncommon for random sampling to catch errors at the same rate as a comprehensive review. Specialist firms in claim auditing possess advanced software and systems far superior to generalist companies. They also have extensive knowledge of the complexities surrounding medical and pharmacy claims, which must be handled carefully, given the many data points involved. The most significant financial opportunities often lie in identifying and correcting systemic errors. When errors repeat according to patterns, they can become million-dollar problems.

Many claim auditors have experience working in the technology divisions of major health carriers, gaining a deep understanding of the daily processing of thousands of claims. This expertise allows them to establish systems that check for every detail and present the findings in clear, comprehensible data. Initially, claim auditing emerged from regulatory needs, but it has since transformed into a valuable management tool that enhances both financial outcomes and member services. As technology continues to advance, auditors will be able to provide increasingly accurate results at lower costs.