In the early days of self-funded health plans, audits were looked on as a regulatory requirement rather than a plan management opportunity. But things have changed, and plan managers understand that medical bill auditing services play a crucial role in excellent plan management practices. Most claims today are paid by third-party administrators (TPAs), which means there is a need for greater oversight than there might have been when processing was handled in-house. Making sure TPAs ​​are meeting their performance goals is essential, along with double-checking overall plan performance.

If there was one lesson self-funded plans learned recently, it was the significant effect an unexpected event like the coronavirus pandemic can have on medical costs. It upgraded the budgets and changed the claim payment experience for many plans with extraordinary claims for hospital expenses and other care. When claim volume increases and covered costs arrive on complex bills with hundreds of line items, the opportunity for errors and overcharges is extraordinary. Audits and the continuous monitoring that many plans put in place after the pandemic are one way to review what happened.

Unfortunately, some unscrupulous people would use a pandemic to cover fraud and abuse, but some did – especially with pharmacy benefit plans. Auditors with sophisticated software that reviews 100-percent of claim payments have been especially helpful at detecting patterns of fraud and abuse. It's another reason that auditing has become a hot topic as plans normalize their payments and operations after the pandemic. Continuous monitoring service from auditors also helps for ongoing management and is a strategic tool that helps in-house managers. Real-time data is always helpful.

The never-ending improvement in proprietary audit software also gives auditing firms specializing in medical claim reviews more to offer every year. They have years of expertise checking claims payments for self-funded plans with TPAs ​​and understand every possibility in the business. They're fast at rooting out errors that might have been missed in the random-sample audits of years gone by. An audit these days typically helps recover overcharges and mistakes with a value four times the audit price. It's an eye-opener for plans that have not had their claims reviewed by a firm with high-level capabilities.