The goal of every medical plan is to pay claims accurately and with consistency according to the plan documents for covered services. But with most self-funded plans now outsourcing claim payments to third-party administrators, there needs to be oversight to make sure things go as planned. It's where medical bill auditing services come in as they review the work of TPAs to check for accuracy and adherence to plan documents. The dollar figures are large with medical claims, and excellent auditing to flag errors and help recover overpayments is essential. It's why plans no audit more often.
Auditing is one of the areas where advances in technology, specifically recent software, have made a vast improvement in years. When a layer of human oversight is added to the electronic review, there is unmatched accuracy. The best claim auditors now check 100-percent of claims paid, and it's a leap ahead versus random-sample audits. When every claim payment is double-checked for correctness, it gives in-house plan management a clear picture of how well a plan is performing or not. The COVID-19 pandemic put plans under unprecedented pressure, and many are analyzing the lessons learned.
Ideally, self-funded medical and pharmacy benefit plans are monitored continuously for claim payment accuracy. It's real-time auditing that provides instant insight into a TPAs performance and the claim experience of the plan. One of the significant benefits of watching continuously is to flag errors while they are still minor problems. When they are corrected before they become large issues, it saves time and money while serving members better. It's also easier to recover overpayments when they are recent and small than larger and longer in the past. Well-managed health plans save money.
The increased use of audits and monitoring is a tribute to the industry's improvement in accuracy and value in recent years. It's no longer unusual for an audit to flag recoverable overpayments of four times its cost. When large employers, both corporate and nonprofit, with self-funded benefit plans hear these numbers, their interest increases immediately. There is a significant opportunity to lower health care spending while delivering the same level of quality care to employee members. It's a far cry from the days of random sample audits that were infrequent and chiefly to comply with regulatory requirements.