In the healthcare insurance world, prescription drug audit companies are receiving more attention in the wake of the COVID-19 pandemic. Highly accurate reviews of claim payments have produced factual data about medical costs and utilization during one of the most unprecedented periods in recent times. As a result, usable and easy-to-read (and understandable) reports have great value. If you're representing an employer-sponsored plan interviewing audit firms, ask about their reporting style. Their ability to deliver data most straightforwardly will enhance the value of their work. You want easily usable data.
Claim audit firm clients are wise to begin the process with a list of deliverables from the audit. They can go beyond standard error detection with mutual agreement and depending on the auditors' capabilities. If there are things you need to understand about your claim experience that aren't coming through in reports from your third-party processor, auditors can help. When they report findings in clear reports outlining the pertinent details, you have an excellent plan management tool at your fingertips. There's no reason to stop after the audit. Consider keeping the service and receiving more reports.
Understanding why today's claim reviews and their reports have become so much more important comes back to 100 percent auditing. It's different from random sampling when each claim is double-checked. There's no way a random sample can compete with that sort of scrutiny. The results are affordable and impressive when done by robust electronic systems that work nearly instantaneously. There are few services you can retain that add funds to your budget, but claims audits are one of them. The recoverable errors it flags are worth far more than the price of an audit.
Who benefits the most? Nearly always employer-funded medical and pharmacy plans with claim administration outsourced to third-party processors. Almost every service agreement has performance guarantees, but are they being met? Routine or continuous auditing can confirm that promises are fulfilled and call out potential system fixes. In a perfect world, all claims are paid the first time accurately. When systems are tightened or adapted to each plan's special provisions, the chance of future errors diminishes. Better yet, audits today review 100 percent of payments and double-check them.
