Are You Up to Speed on Healthcare Auditing?

In one way or another, employer-sponsored health plans have a way of making news. In one of the latest ways, lawsuits filed by several plans again claim administrators are in the headlines. Various means, likely including a healthcare audit, have led plan sponsors to allege they have been overcharged substantially for years. The dollar amounts total in the millions, and the lawsuits are substantial. They signal a breach in the relationships between sponsors and large health carriers administering their plans. If the allegations prove true, it's another reason why frequent and active plan oversight is essential.

Claim auditors can find routine errors and irregularities but can also detect far more significant issues for health plan sponsors. It depends on the audit setup and what is being reviewed. If you manage a plan and select an auditor with significant medical billing knowledge, the chances of detecting systemic issues that cost your plan thousands, if not millions, of dollars, may be higher. It also explains why claim auditing is revenue-neutral or positive. It's rare for an audit to cost more than the recoverable errors it flags, showing why plans audit more often. You can also go as far as monitoring claims continuously. 

Technology has driven claims review improvements, and accuracy and speed continue to make gains. When the electronic portions of audits become more accurate and insightful, it reduces the staff time required to conduct one. Today, it's faster and easier to audit 100 percent of claims than it used to be to conduct a random sample. When you review every payment, the results are consistent and can be compared year to year. When you randomly sample, the results are different each time and less valuable for ongoing comparison. Today, keeping your plan on track in many ways is more doable.  

Given the many advantages of auditing claim payments or monitoring them continuously, you can understand who plan sponsors are on board. There continue to be regulatory and compliance benefits, fiduciary best practices gains, and help for the bottom line. When large sums are going out the door daily and handled by third parties, the imperative for oversight is obvious. The coronavirus pandemic was another example. Plans that were audited routinely or monitored continuously were better positioned to deal with the sudden spike in utilization. They understood their costs better.