The aftermath of the coronavirus pandemic has led to a significant need for rebuilding and reassessing various sectors, including the medical and pharmacy benefit plans of large corporate and nonprofit employers. To navigate this complicated landscape, these organizations increasingly seek assistance from medical claim auditors. The pandemic taught plan sponsors that prompt review of claim payment is essential. With an unprecedented surge in medical utilization, many plans faced dramatic overcharges and skyrocketing costs as they grappled with increased claims over more than a year.

Claim audits represent some of the more intricate aspects of this review process. They involve a numerical assessment and require a deep understanding of medical coding and claims processing nuances that contribute to data accuracy. This complexity underscores the value of employing firms that specialize in healthcare auditing. These organizations often boast extensive experience in managing health plans and overseeing claim payments, enabling them to offer detailed reviews that identify a wider range of errors. A careful audit setup also focuses on your pan's unique provisions.

A rising trend is the use of real-time audit software, which allows for ongoing reviews of claim payments. This approach is particularly beneficial for employers that fund their benefit plans and are highly invested in achieving accuracy to protect their budgets. Managing error rates, particularly aiming for a reduction below the commonly cited three percent threshold, can bring significant financial benefits. Consistent oversight of third-party processors enhances employers' ability to manage claim payments effectively. Even if an audit reveals no discrepancies in external processor payments, the process still proves worthwhile, confirming the accuracy of their claims management.

Since no two self-funded plans are the same, each featuring unique provisions, reputable audit firms take a meticulous approach by examining these nuances closely and incorporating them into their auditing systems. Since many claim processors are large health carriers, their generic methodologies may overlook specific plan provisions. The processors may not optimally serve plan members if payments don't meet specified criteria. Thus, while the auditing process can be intricate, specialized firms are adept at simplifying it through their expertise and innovative solutions to maximize the audit's value.