Performance and cost containment improvements are typical for health plans that audit their claim payments routinely. Medical claim auditing, and pharmacy claim reviews, are compliance issues for employer-funded plans, but they do more. With claim administration nearly universally outsourced, audits have a highly valuable oversight function. Sophisticated electronic reviews today check all claims paid, and the accuracy of their reporting is impressive. Audit reports lead to wide-ranging insights about plan performance. Capable auditors can add review items that are specific to your plan.

It's common today for claim administrators to drive error rates down to three percent or less. The pitch is that your plan is performing well when they become that low. But what if it was easy to get them even lower? Auditors can help ensure your plan is performing to its full potential. System setup is a significant issue and opportunity for a claim processor, but some details of your plan's provisions may have been overlooked. When an auditor flags irregularities, it can lead to easy fixes that improve accuracy. Members are served better when claims are paid correctly and consistently.

Each plan's unique provisions create opportunities and complications for claim processing; yours are no different. Therefore, auditors need to be meticulous in their setup and take time to learn what to look for in your claim administration. Sometimes, third-party administrators process your claims as they handle their own if they are large health plans. In many respects, it's beneficial, but nuances might be overlooked. Depending on how your plan is structured, they may add up. On the provider side, coding errors and duplicate or overlapping services can drive up costs needlessly.

The goal of health care plans is to provide members with needed care but well managed. An open checkbook without coordination only leads to more expenses without improving care delivery. Auditing can improve plan management and provide insightful oversight. The data is the basis for meetings and initiatives to improve things financially and the care delivered. When audits turn up surprising data, something no one expected to find, they are especially beneficial. It's one of the reasons why engaging a specialist claims auditor can help. They bring specific capabilities to the table.