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Lovely Dimez Group

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Claim Audits Bring Powerful Oversight

If there's one thing that's certain about medical claims auditing , it provides oversight that's second to none. Employer-funded health plans pay millions of dollars in monthly claims, and keeping tabs on the administrators making the payments is essential. Auditors with experience in the field know where to look for errors, and they also check based on your plan's provisions – each plan covers different items with specific parameters. Indeed, claim processing accuracy has markedly improved in recent years, but oversight remains necessary. Auditors have expertise that adds value to their work.

The proper pre-audit setup is crucial and includes zeroing in on your plan's covered services and medicines. Most third-party claim administrators are large health and pharmacy benefit management plans with their own systems and lists of covered items. You can piggyback on their arrangement to a large extent, but it may also have unique provisions. The best claim audits consider every detail and ensure that nothing is overlooked. Claim administrators have been known to use their ready-made systems without spending sufficient time adapting the system for your claims as required.

Similarly, implementation auditing is critical and should occur about three months after you've started with a new processor. When things get off to the right start, it minimizes errors later, avoids million-dollar problems, and sees that members are treated well. If your administrator has made accuracy guarantees or set targets, an audit is an excellent way to keep them honest and ensure agreements are honored. Auditors only consider your plan's best interests and look at claim payments objectively. Running oversight on a different system that's built to do such reviews ensures better results in the long run.

Keeping audit software running continuously is trending as employer-sponsored plans keep closer tabs on their claim payments. It's a significant cash outflow with potential errors, so it makes sense. When auditors flag errors in real-time as they occur, you can stop future similar ones and recover the improperly made payments. Medical billing is complex and ever-changing as new treatments and medicines are introduced. Even processors with low error rates can have a learning curve when adjusting to new practices. When you have an ongoing claim payment review, your plan is covered.


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