For years, every health plan in the United States has been faced with skyrocketing costs for medical services and prescription medicines. Then along came the coronavirus pandemic, and it made a persistent challenge into a sprawling problem. Therefore, there's no doubting why self-funded plans have turned to medical claims auditing with increased frequency to more closely understand their claim experience. It's never been more essential to correct mistakes and recover overcharges than it is today. The post-pandemic landscape for many things has changed, and medical claim payments are one of them.
The once-in-a-lifetime coronavirus year also occurred in an era where most self-funded plans outsource their claim payments and processing to third-party administrators. It means the money flowing out the door is happening offsite and not under in-house managers' direct, daily control. It's why the need for oversight has never been greater, and it's more common than ever for plans to audit themselves and even monitor payments continuously. Experience has shown that catching (and correcting) error patterns while still small is far preferable to cleaning up large messes of overpayments after the fact.
Health plan members with high-deductible coverage also benefit customarily from more accurate claim processing. They also have been hard hit by pandemic-related medical expenses and need the benefit of stricter oversight. TPAs are usually large health insurance carriers with complex claim processing protocols and their way of doing things. Making sure they follow the plan documents for self-funded company programs they manage is vital. It's all too easy (and common) for their people to operate on auto-pilot and overlook a plan's unique nuances. Over time, things can veer far off course.
What's most impressive about today's claim auditing is its extraordinary accuracy. Sophisticated software can review 100-percent of claims quickly and efficiently. It keeps audit costs down and productivity high. The best auditing firms flag overcharges that can be recovered in significant quantities – usually with a value about four times the audit price. It's the same with continuous monitoring and plans that check claims in real time are among the best managed in the business. As medical costs continue to skyrocket and after the COVID-19 pandemic, managing claim payments is crucial.