Most large- and mid-size U.S. corporations self-fund their employee health plans and audit them periodically as required by regulators. But given the significant financial exposure of health and pharmacy benefit plans, increasing oversight of them is crucial. Medical claim audit companies are growing in the sophistication of the services they offer. The current gold standards are audits covering 100-percent of claims followed by continuous claims monitoring. Together, they help companies manage their health and pharmacy plans more effectively. Costs are managed, and members are served.
If you're someone who has questions in general, hearing answers about the kinds of errors 100-percent audits catch might win you over. One excellent example is filling prescriptions with costly name-brand products when generics are available – and your plan specifies that they are used. A complete review of your pharmacy benefit plan will catch all of these errors instantly, and you can take the data directly to your claim processor. There are countless other examples of similar details that you can closely manage with more detailed auditing done more frequently. The audits are budget neutral or better.
For anyone who has the in-house role of managing medical and other benefits plans, the value of auditing and monitoring services is enormous. It takes you from being defensive when questions arise to a proactive manager who has concrete answers. High-performing plans please management and shareholders alike, and they also serve employee-members better. Only a 100-percent audit with a high degree of accuracy can bring you close to the level of detail you need for superior plan management. If you've gone over budget in past years, this is an excellent way to stay on track.
One of the most significant recent innovations in self-funded plan management has been continuous monitoring of all claims. When your auditor watches in real-time and reports its findings to you each week or month, you'll catch errors immediately and have them corrected when they are small problems. When a complete audit is undertaken, you won't face a mess to clean up and months of difficult negotiations with claim processors and providers. Every company that has signed up for continuous monitoring has seen significant improvement, and its medical plan operates more effectively.