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luvibee Group

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Dig Deeper in the Details with an Audit

Corporations and large nonprofit organizations sponsoring health and pharmacy plans for their employees have much on the line. It helps explain why medical claim auditors are in such high demand. They help untangle the situation with errors and overpayments, leading to recoveries and preventing future mistakes. As auditors encourage your claim administrator to work more accurately, your plan will save money, and members will be served better (and equally). The fiduciary responsibility of large plans has come into the spotlight recently with class-action lawsuits alleging poor performance in some areas.

Making reports clearer and more actionable is a feature of today's claim audits. No longer do you need to sift through voluminous data to find answers. They report in plainer and easier-to-read language, which increases their value. When you meet with your claim administrator for update meetings, imagine the difference when you have a factual audit report in your hand. You can also manage the process by posing questions in the pre-audit meeting to ensure that your most pressing issues are addressed. Customization is a pre-requisite to an effective claim audit – you want to have it tailored to your plan.

One of the most insightful and helpful opportunities is having the same auditor routinely check your plan for an apples-to-apples comparison. You can watch trends as they begin and become more prominent and check to see that repeating errors are stopped. In the earliest days of auditing, when random samples were the only method, audits never looked the same way twice because the sample changed each time. Now, when you audit a batch of claims twice, you'll see the same results unless there is an intentional adjustment of the factors reviewed. It means you can count on the results.

When interviewing prospective audit firms, don't hesitate to ask questions. Like anything else, they aren't all the same. You'll find some scrappy independents in the business who have honed their skills and systems over the years to become impressively accurate. It's not to say the big guys can't produce a decent claim audit, but the people who specialize and do it every day hands-on have a way of finding things the others can easily miss. Smaller firms also have shorter client lists, and you have greater peace of mind knowing they only represent you. A single-minded focus works to your advantage.


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