Accurate Audits Improve Self-Funded Health Plans

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Accurate Audits Improve Self-Funded Health Plans

Posted By TFG Partners     October 21, 2021    


Not that many years ago, quite a few self-funded medical plans scheduled claim audits only to comply with government requirements, and their auditors checked random samples. Had those practices been in place in the aftermath of the COVID-19 pandemic, there would have been much less oversight of claim payments after a difficult year. But, thankfully, today's better medical bill auditing services review 100-percent of claims rather than random samples, and audits happen more frequently. Nearly all self-funded plans now view claim auditing and continuous monitoring as strategic management functions.

What began as a compliance and regulatory function has improved and evolved into an oversight mechanism that in-house plan managers regard as vital. Many minds were changed when software advances enabled 100-percent audits that led to asset recoveries far higher than the audit cost. It also ensured members were being served fairly and evenly and put in-house staff in a much stronger position for conversations with third-party administrators (TPAs). It's common for TPAs to make accuracy guarantees, but it can be tough to know if they are performing as promised without oversight.

Independent specialist auditing firms working only in the medical and benefit claims sector have also taken the industry to a new level of accuracy. Many are staffed by executives and staff with experience at major health carriers in the claim payment area. They have brought their expertise to the audit side and leveraged their knowledge to make significant improvements. Their proprietary methods and technology offer self-funded plans an unprecedented level of accuracy and insight. It also gives self-funded plans an extra layer of protection against fraud and abuse when audits check all payments.

Large employers, both corporate and nonprofit, have been so impressed by the more accurate audits that many have added continuous monitoring. It's a real-time service that runs on the same software and methods as audits do but provides updated data continuously. When there are increases or unexpected trends in claim payments, concrete answers about the payment activity are available. For corporations with quarterly earnings reports that can be affected by expense increases, having the data to provide thorough explanations is crucial. It also facilitates better and consistent plan management.