There is little doubt that medical claim audits are an effective way to run oversight on an employer-sponsored health plan. Claims drive costs, and accurate claim payments see that members are served well and equally. When mistakes are made, it affects the bottom line and member service—every well-managed plan benefits from double-checking all its claim payments and the work of outside third-party processors. Given the complexity of each claim and the recent spike in utilization driven by the coronavirus pandemic, health plans are under pressure. Reviewing claim experience is increasingly vital.

Auditing pharmacy benefit plans can be just as important as medical claims. Even with very low error rates, the costs for some medicines are so high that tiny mistakes can add up. There are also low-hanging fruit-type scenarios, such as scripts filled with name-brand medications when generics are available. A sophisticated audit system can root out those errors in a single pass and tell pharmacies that generics must be dispensed when available. The same goes for other providers, and when oversight is in place, and they receive notifications about overcharges, they will self-police more actively.

Better auditors don't require much if you're in-house at a company or nonprofit with a self-funded medical plan concerned about staff time. Their electronic claim and expert reviews are accurate enough that very little time is required for the plan sponsor's staff. It's another reason to audit more often and enjoy cost savings and plan management support. The findings can be surprising when special provisions are added to the audit system, and each one is checked. Opportunities exist to drive any error rate lower, and oversight is how to do it. The cost of the service covers everything you'll need.

Working with an auditor for ongoing plan monitoring is another option, and many plans have been added since the calamity of the coronavirus pandemic. With audit software running continuously and frequent reporting, every mistake is flagged in real-time. It's a revelation to plan managers more accustomed to periodic auditing. Keeping things cleaned up constantly means there's never a crunch time when an overload of error recoveries needs to happen. Handling them incrementally is much more orderly and helps minimize costs and budget swings. It's unquestionably the better plan management approach.