The coronavirus pandemic impacted various sectors, including health plans. In its aftermath, medical claim audits were essential for understanding the shifts that occurred. Large employers that self-fund employee benefit plans faced challenges as healthcare utilization rates surged, coupled with rising prices. With ongoing inflation and the typical annual increases in healthcare costs, auditing claims has emerged as a practical strategy. While periodic reports from external processors hold value, it’s imperative to maintain oversight and review their self-reported findings.
An independent auditor’s examination often reveals critical insights. The evolution of claim auditing presents a narrative driven by technological advancements. A key advantage noted during the pandemic was the sophistication of audit systems and software, particularly those developed by specialized firms. These tools enabled a review of every claim, verifying thousands of data points. Plan sponsors could customize their audits by adding specific questions beyond the routine points. When the final report is generated, a lot of factual data is available that examines various aspects of the claim experience.
As new tests and treatments emerged, alongside their associated costs, a learning curve existed for claim administrators. Initially, confirming the accuracy of these payments was crucial. Identifying patterns of errors early on is vital in preventing them from evolving into more significant, costly issues. It underscores the importance of conducting audits frequently and promptly. Allowing discrepancies to accumulate and attempting to recover overpayments long after they occur can prove challenging. Monitoring these payments within the plan year is more effective when actions can be taken more readily.
Alarming stories regarding overcharges surfaced during the height of the pandemic. Although many of them have since been resolved, they highlight the need for ongoing vigilance. Implementing continuous monitoring, where audit software operates in the background and produces monthly reports on claim experience, is a proactive approach. It helps plan sponsors stay informed about cost trends and detect error patterns early, addressing them while they are still manageable. Navigating the complexities of healthcare claim payments necessitates robust oversight to facilitate more effective management.
