The after-effects of the coronavirus pandemic are still impacting various sectors, including employer-funded medical and pharmacy plans. One change is the increased use of medical and PBM auditing services. Auditors review claims to verify costs and to identify errors. The emergence of new testing and treatment protocols during the pandemic led to cost increases. Initially, certain expenses bypassed the usual checks that typically ensure reasonable and customary charge limits, leading to overbilling that made headlines. This context explains why plan sponsors are keen to review their claims meticulously.
Claim auditing is often seen through the lens of financial and compliance measures, but it also plays a role in service to members. Ensuring consistent payment for all members is essential, especially for those enrolled in high-deductible plans where accurate payments matter. Audits can improve efficiency by identifying recurring mistakes within the claims process. It's far more effective to prevent errors than to try to recoup funds from incorrectly paid claims. Since claim expenses directly affect the balance sheet, companies—especially public ones—must ensure accuracy for use in quarterly earnings reports.
The shift from random sample audits to 100-percent claim reviews has caught the attention of plan sponsors. This comprehensive approach has revolutionized the industry, significantly enhancing accuracy in payments. As a result, audits have begun yielding recoveries and savings that can be four times their costs, transforming audits into a valuable management tool that is both budget-friendly and effective at improving claim payment accuracy. It's no wonder that many plan sponsors have opted to audit their claims more frequently than what regulations require.
Additionally, the entry of professionals with health plan experience into the claim audit field is noteworthy. Their expertise in the complexities of medical claims, coupled with technology know-how, has significantly improved audit outcomes. They know how to develop claim review systems that can delve deeper than what a typical financial auditor might achieve. Expanding this skill set to encompass a broader range of factors boosts both the accuracy and value of claim audits. Large employers who sponsor health and pharmacy benefit plans are certainly taking note of these improvements.