When people think of auditing, they often associate it with finance and tax matters, but its importance in the healthcare sector is growing. Healthcare auditing companies provide vital tools for cost containment, as they help verify the accuracy of claims. Any irregularities identified can lead to the recovery of significant unnecessary expenses. Even minor error rates can accumulate substantial financial losses. There are often opportunities to enhance systems that consistently make errors or overlook questionable items. Auditors who are well-versed in medical billing provide the greatest value.
Over the years, system advancements have enabled electronic reviews to catch nearly all irregularities. However, having a final human review of the reports remains essential and is integral to a robust audit process. The setup is also crucial since each plan has its unique provisions. Tailoring the audit specifically to your plan can uncover many additional inconsistencies. This principle also applies to implementation auditing, which should ideally occur about 90 days after transitioning to a new claim administrator. Auditors can identify more errors and recoverable amounts by closely examining billing and coding.
Claim audit firms specializing in this area have made considerable progress. They merge their expertise in medical billing with auditing skills, resulting in more detailed and targeted reports. Collaborating with an auditor over time allows for comparisons between different periods. This practice signals to third-party administrators that your plan maintains diligent oversight, motivating them to work more carefully and to self-monitor for errors. Many plans see gradual improvements as they remind TPAs of previous mistakes. Although error rates may be very low, the impact of overpayments can still be significant.
In the wake of the pandemic, many health and Rx plans are now under continuous auditor surveillance. Auditors provide monthly updates that offer near real-time insights into plan performance and highlight any errors. Well-managed plans leverage continuous monitoring to serve members and bolster cost-containment efforts effectively. While claim administrators have reduced error rates to minimal levels, oversight remains crucial. Even highly accurate systems can make mistakes, and catching these errors promptly is key to recovering overpayments and preventing similar issues from occurring in the future.
