The Trend Toward Frequent Claim Audits

Large employers of all types increasingly choose to self-fund medical plans for their employees. This approach offers several advantages, but it also brings significant responsibilities and substantial financial risks. As a result, more companies are turning to medical claims auditing services to ensure meticulous oversight of their claim payments. In most cases, third-party administrators (TPAs), typically large health insurance providers, handle these claims on behalf of self-funded plans. While TPAs generally perform thorough work, consistent oversight remains essential to safeguard against potential issues.

Today’s leading claim auditors adopt a comprehensive approach, meticulously reviewing 100% of payments to deliver an accurate assessment of a plan’s performance. They analyze member service quality and costs, comparing the actual charges with the expected charges. Specialized claim audit firms are well-versed in identifying common mistakes, fraud, and other abuses due to their extensive experience with various plans and payment structures. This thorough auditing process also equips in-house plan managers with valuable data, transforming it into a powerful management tool.

While TPAs frequently make performance guarantees, verifying their work through diligent audits is a prudent strategy. The landscape of self-funded medical and pharmacy benefit plans was dramatically altered by the coronavirus pandemic. For plans that had not previously engaged in regular auditing, the pandemic underscored the critical need for scrutiny of claim payments amidst an unexpected context. The crisis revealed numerous overcharges for certain services, exacerbated by legitimate expenses incurred by plan members who required hospitalization during the recent coronavirus pandemic.

Companies and large nonprofits increasingly view audits as financially advantageous opportunities, often recovering overpayments that exceed the costs of the audit—by a factor of four or more. Properly managed plans that maintain strong oversight realize financial gains and enhance member experience, providing better service and increasing trust in their healthcare benefits. By prioritizing thorough auditing and oversight, employers can strike a balance between financial prudence and enhanced member satisfaction. Claim audits also meet regulatory requirements and fiduciary responsibilities.