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Salish Stories Group

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The Impressive Insight of Claim Audits


Claim auditors are allies for companies and large nonprofits self-funding their benefit plans. A healthcare audit will reveal much about medical and pharmacy plan performance, and it's similar to other employee benefit claims. It's nearly universal that self-funded benefit plans use third-party processors and pharmacy benefit managers. Today, they have excellent accuracy and ultra-low error rates. However, the claim volume is high for many plans, and the complexity makes things fall through the cracks. When auditors catch and flag mistakes, you can push error rates close to zero.


Software advances that continue each year have turned claim auditing from a regulatory and compliance function to a management tool. It's a game changer when you can pose any question about your claim payments to an auditor and receive an answer for 100 percent of your payment. Firms specializing in the field have led the way and continuously improved their systems and methods. They've made it cost-effective (and an excellent oversight strategy) to keep their software running the background year-round. You'll receive monthly reports, be aware of every irregularity, and much more.


It's also interesting to compare auditor's reports with the ones you receive from your claim administrator. When things align, you'll know things are running smoothly – if there are discrepancies, the conversation about what needs to happen to correct the mistakes opens up. You'll see considerable improvement over the long haul, and active oversight beats the surprise of a million-dollar problem every time. It's natural for claim administrators to work more carefully and conduct more active oversight when they know you have an independent third-party auditor watching their work.


Health and pharmacy benefit plan sponsors that only audit when required for compliance miss substantial opportunities. Once you've viewed audit reports, you'll understand the opportunity. Having factual data routinely changes the game. If there are mistakes, you can decide when and how to request reimbursement for overpayments. Recovery is generally more straightforward and less complicated when you do it shortly after the fact. Working a year or more in arrears puts providers and administrators in a difficult spot. Letting them not promptly make it easier, and there's less resistance.

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