Advances in Medical Claim Audits

Rapid technological advancement has dramatically reshaped numerous industries in recent years, and corporate benefits management is no exception. Medical claim auditing, in particular, has evolved thanks to increasingly sophisticated software. Today, it is standard practice to review 100 percent of claims during an audit, offering a level of accuracy far superior to random sampling. Both corporations and nonprofit employers operating self-funded plans are leveraging these technological improvements. Many now incorporate claim payment monitoring services to extend the audit process in real time.

With the growing trend of self-funded plans outsourcing claim payment processing to third-party administrators (TPAs), the need for robust oversight tools, such as claim payment monitoring, has become essential. TPAs, often representing extensive health plans, may commit to a high standard of payment accuracy to secure your business. However, verifying their performance requires careful, ongoing audit and monitoring. This process enables transparent discussions between your internal team and the TPA’s representatives, fostering a data-driven approach to problem-solving. 

Rising costs can be challenging to diagnose, as multiple factors may contribute to the increase. Reviewing all claims with advanced software provides unprecedented transparency, making it easier to pinpoint trends and anomalies. The financial stakes are high: self-funded medical and pharmacy plans carry significant exposure, potentially impacting quarterly earnings and stock prices. In times of crisis, such as during the coronavirus pandemic, the value of a well-managed, closely monitored benefits plan becomes especially apparent. Accurate claim payments also directly benefit members.

The shift toward continuous claims auditing is largely driven by the relatively low cost of these tools compared to the value of detecting errors. Previously, payment mistakes often went unnoticed until they accumulated into large financial losses. Today, early detection is routine, allowing for system improvements that help prevent future errors. A proactive approach also ensures that claim payments remain consistent with plan documents and promised benefits. Each benefits plan has complexities, and strict adherence to these details is key to maintaining budget discipline and member trust.

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