Every medical claim paid is a complex endeavor. One way for employer-funded plans to police the accuracy of their payments is a healthcare audit. Reviewing each payment made by a third-party administrator or pharmacy benefits manager is a crucial oversight function. Catching and correcting significant error patterns is vital, but so is finding individual mistakes. Taken together, minor errors add up to substantial sums for many plans, and flagging and correcting them makes a difference. It supports cost containment efforts and improves member service when claims are paid correctly with consistency.


The audit setup is one of the most crucial parts of the process because everything flows from it. A one-size-fits-all approach won’t yield the benefits of a customized configuration. The nuances of each plan need to be addressed by the audit software, ideally by someone with equal expertise in medical claims and audit techniques. It’s why all claim auditors aren’t alike, and selecting the best makes a difference. They bring years of expertise and a specialized approach that adds value. There is no substitute for working in the field daily, staying current with trends, and continuously improving.


As claim audit technology and systems become more sophisticated, the electronic portion of the process becomes more complete. It reduces the need for human oversight and saves time while boosting accuracy. Specialist claim auditors refine their software after each project and have made impressive quality gains in recent years. It has increased recoveries and brought down the cost of auditing because refunds of overpayments and mistakes offset it. In today’s world, audits often lead to recoveries of four times their price. Their budget friendliness has caught the eye of senior management at most plans.


Your claim auditor’s independence also matters. When there is no objective other than to help your plan pay claims accurately, save money, and serve members well, it works best. The unique expertise claim auditors bring to the project also matters. Most have staff executives with prior health plan experience with years of claim administration experience. They understand how to set up the audit, what to look for, and where the most significant recovery opportunities exist. Often their services cost no more than others with less expertise. Traditional audit firms are focused on tax and finance issues.