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Bigger isn't always better, and when it comes to medical claims auditing, smaller, independent firms are often the best. It's because some firms specialize in claim audits and do nothing else. Their total focus on claim reviews gives them particular expertise that's tough for larger firms to match. Many count executives with prior health plan experience among their management, providing them with an insider's view of the industry they're auditing. They know the ins and outs of medical and pharmacy benefit plan claims and how to audit them thoroughly. It also helps report the findings more clearly.

Since the 1990s, there's been a continual advance in audit software, and claim auditors who have been in the game since then have the advantage. Their proprietary systems review each payment with an unprecedented level of accuracy. The concise data allows for easy-to-read and understand reports that put plan sponsors in an excellent position to work with their outsourced claim processors. The entire process is designed to improve efficiency and reduce the amount of time anyone needs to review the data. It frees up time for plan sponsors to focus on cost-saving opportunities.

Auditing matters most to large employers that self-fund their plans. With the trend to outsource claim payments, they need reliable oversight. The audits have evolved from their original role as a compliance function into the strategic management tools they are today. Third-party administrators (TPAs) have undoubtedly improved their processing accuracy through the years and plan sponsors' benefits. But audits will show where additional opportunities lie. If you're in a plan management role and have not frequently been auditing, you may be surprised by how much a 100-percent review will turn up.

The latest claim audit trend is a continuous monitoring service with monthly reporting. It catches mistakes and processing errors in real-time and reports them. Recovery is more straightforward, and systemic correction is easier when irregularities are detected nearly immediately. Never letting an error multiply into a million-dollar problem is the goal of ongoing claim processing monitoring, and it's easy to see the long-term value. The recent coronavirus pandemic was an extraordinary event for most medical plans, and the ones that had auditing and monitoring in place kept things under control best.



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