Medical and Rx costs commonly lack transparency, making medical claim and pharmacy benefit manager audits essential for financial control. The top five health plans in the U.S. rival the largest tech companies in terms of dollar volume -- and health care expenses, like technology investments, are among the most significant outlays. However, whereas technology spending builds infrastructure and drives efficiency, healthcare costs are ongoing, routine, and rarely prioritize prevention. Recent progress in software now allows for the review of 100% of medical and pharmacy benefit claims in audits.
Full-scale claim audits provide a much higher level of accuracy, which is increasingly necessary to manage and control escalating costs. The era when self-funded corporate medical plans only performed minimal audits to satisfy ERISA or other regulations is over. Today, claims audits are recognized as valuable management tools. If you manage a self-funded plan, it is vital to require 100% audits that not only flag overpayments and payment errors but also address systemic issues. Even the most diligent claims administrators make mistakes, and each error unnecessarily costs the company plan.
Many self-funded corporate health plans have discovered that auditing medical and pharmacy benefit claims adds substantial savings to their budgets. Recoveries from these audits often far surpass their cost. The financial advantage originates from advanced claim auditing software and refined auditing processes. Pioneers in this field began auditing 100% of claims in the 1990s and have continually improved their methodology. While several other firms now offer full-claim audits, experience and access to superior screening and error detection tools are still key for achieving the best results.
Given healthcare costs, companies are adopting ongoing claim monitoring as an additional cost-control measure. This process utilizes software and techniques similar to those used in audits but applies them on an ongoing basis. Real-time review of claim payments enables early detection of errors and irregularities, preventing minor errors from growing into larger problems. The right claims administrator can help ensure these issues are corrected quickly, limiting employee overpayments—an especially important consideration as more plans feature high deductibles and consumer-driven designs.
Full-scale claim audits provide a much higher level of accuracy, which is increasingly necessary to manage and control escalating costs. The era when self-funded corporate medical plans only performed minimal audits to satisfy ERISA or other regulations is over. Today, claims audits are recognized as valuable management tools. If you manage a self-funded plan, it is vital to require 100% audits that not only flag overpayments and payment errors but also address systemic issues. Even the most diligent claims administrators make mistakes, and each error unnecessarily costs the company plan.
Many self-funded corporate health plans have discovered that auditing medical and pharmacy benefit claims adds substantial savings to their budgets. Recoveries from these audits often far surpass their cost. The financial advantage originates from advanced claim auditing software and refined auditing processes. Pioneers in this field began auditing 100% of claims in the 1990s and have continually improved their methodology. While several other firms now offer full-claim audits, experience and access to superior screening and error detection tools are still key for achieving the best results.
Given healthcare costs, companies are adopting ongoing claim monitoring as an additional cost-control measure. This process utilizes software and techniques similar to those used in audits but applies them on an ongoing basis. Real-time review of claim payments enables early detection of errors and irregularities, preventing minor errors from growing into larger problems. The right claims administrator can help ensure these issues are corrected quickly, limiting employee overpayments—an especially important consideration as more plans feature high deductibles and consumer-driven designs.