Corporate and nonprofit employers that self-fund their benefits plans must prioritize the accuracy of claim payments, particularly given the annual rise in health plan costs. Medical claim auditors are increasingly crucial, offering second opinions that validate payment accuracy or highlight discrepancies. Maintaining active oversight is essential with most claim administrations outsourced to large health plans. While many of these plans assert accuracy through self-reporting, independent external audits can provide valuable insights. An auditor's independence always helps.

If you're managing a sizable self-funded plan, use your initial consultation with the auditor to identify specific areas of concern. They can help pinpoint significant opportunities for cost containment and allow you to assess them against your organization's needs. Conducting a comprehensive 100-percent claim audit gives you an edge over traditional random sampling methods, significantly enhancing your negotiating power with providers, third-party claim administrators, or pharmacy benefit managers. Leveraging facts and data establishes a solid foundation for discussion based on solid data.

Recognizing that every health plan, member population, and processing system is unique underscores the importance of tailoring audits carefully. Customization is key, and specialized claim auditors possess the expertise to implement it effectively. This approach does not necessarily increase audit costs, as advanced electronic reviews can identify irregularities in great detail. Unlike in the past, when audits primarily detected repeating error patterns through random samples, contemporary practices allow for a thorough examination of all claims, ensuring that even minor mistakes are flagged.

The precision and detail of today's claim auditing yield an impressive return on investment, capturing the attention of self-funded plan sponsors who now conduct audits regularly. Some organizations even engage auditors annually for ongoing monitoring, utilizing consistent systems that generate monthly reports, highlighting any questionable transactions. This proactive approach to claims and monitoring can potentially recover funds exceeding four times the auditing service's cost. Effectively managed plans enhance member service and seize cost containment opportunities.