Audit Claims During Benefit Plan Transitions

Large employers who self-fund their benefit plans are navigating a landscape of constant change, significantly impacting health plans. In this context, medical claim auditors are critical in oversight and management. With most claim administration now outsourced, having an independent claim audit becomes essential for obtaining a second opinion on the accuracy and performance of claims. Auditors can advocate for your plan when third-party administrators or pharmacy benefit managers make errors – effective oversight is wise and essential.

Many auditors demonstrate impressively low error rates and often provide performance guarantees, but relying solely on their self-reports may not ensure complete accuracy. Transitioning to a new claims processor presents another opportunity for an audit. Conducting an implementation audit to double-check your plan's claim payments after 90 days is highly advisable. Independent evaluations of your administrator's self-reports can be revealing. If the figures closely align with the auditor's findings, that's promising. Ultimately, the effectiveness of audits hinges on details, making specialization an asset.

However, if discrepancies arise, addressing them early on can prevent larger issues down the line. This has led to more plans opting for continuous claim reviews, where monitoring services offer monthly reporting to keep you informed in real-time. The COVID-19 pandemic underscored the necessity for robust management and oversight structures among health plan sponsors. Plans that were well-managed during this time significantly outperformed those that were not. Engaging auditors is an effective strategy to uphold fiduciary best practices and ensure optimal plan management.

Access to accurate data is vital, especially when managing outside vendors; independent oversight empowers you to enter meetings well-prepared and informed. When interviewing claims auditors for your company and health plans, consider their area of specialization. Auditors with in-depth knowledge of medical billing can provide the greatest value, as they understand what to look for and are familiar with relevant issues such as coding and duplicate services. This specialized expertise enhances the quality of audits and the data collected, leading to more insightful and compelling reporting. 

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