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Get Claim Audits Right to the Last Penny


Today, it’s widely acknowledged in health plan management that 100-percent claim audits yield more accurate results than random sampling. A healthcare audit with improved accuracy identifies more errors, discovers additional overpayments, and generates more precise reports. For plan sponsors, this presents an opportunity to oversee third-party administrators and pharmacy benefit managers. The increased precision of the audit makes it a more robust management tool and helps plan sponsors manage their claim costs. Given the complexity of the processing function, oversight is warranted.


Advancements in the proprietary software used by claim auditors have driven numerous improvements, allowing for a more comprehensive review of details. The cost of the audit service is also budget-friendly, as it can result in recovering up to four times the price of the service. Those working in the field who have not experienced a 100-percent audit find it a pleasant surprise. The previous random sampling method was more time-consuming and less precise. Today’s audit software can process thousands of claims and produce actionable, accurate data, an excellent management tool.


In addition to the objective of maintaining well-managed health and pharmacy benefit plans, sponsors must grapple with the ongoing rise in healthcare costs. Managing costs while ensuring plan members receive excellent care is the overarching objective, and audits shed light on performance. It’s common for companies today to keep audit software operational at all times for real-time monitoring of claims. The ability to catch and rectify errors quickly is valuable, and it’s also easier to recover overpayments shortly after they occur. Managing discrepancies months or years after the fact is more challenging.


The evolution of claim audits is truly impressive, considering they started as a matter of regulatory compliance. Improved technology also reduces human involvement in the review process, with advancements occurring yearly. Third-party administrators and pharmacy benefit managers naturally exercise greater care in their work when they know oversight is present. Audits serve as a method to confirm whether they are meeting performance guarantees. Given the dollars on the line and the responsibility of offering an employee medical plan, auditing often is always wise.

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