Optimized Claim Audit Set Up Means Everything
Businesses / Posted 2 weeks ago by tfgpartnersseo tfgpartnersseo / 14 views / New
When outsourcing medical claim administration and selecting a pharmacy benefit manager (PBM), it’s a smart approach to build in medical and PBM audits. As claim reviews grow in importance for both providers and health plans, they are increasingly used as a management tool. Making systems easier to audit is logical. Many medical claim errors stem from inaccurate coding, which drives up costs for plans and can prevent providers from receiving the income they’ve earned. This is a key area of concern for auditors, offering substantial opportunities for financial improvement. Getting things right from the start benefits all parties. It also streamlines the process and keeps auditing a consistent part of the process.
With rising medical costs and ongoing budget pressures, accurate claims are clearly beneficial to both medical practices and health plans. While some organizations have internal staff for reviewing claims, hiring outside experts is usually the better choice. Large employer-funded health plans have relied on this strategy for years to verify the accuracy of third-party administrators. The high stakes and the potential to recover from errors are motivating more frequent audits, with some groups now conducting ongoing monitoring of claim payments to catch mistakes in real time.
Advances in audit software over the past decade or two have revolutionized the process. Instead of relying on random samples, 100-percent claim reviews are now achievable because of improved systems. This shift has led to greater accuracy and more detailed reporting. Every claim can be evaluated against hundreds of data points for a precise assessment of outcomes. As a result, sponsors and medical practices audit far more frequently than regulations require. By catching errors or spotting patterns early, issues can be addressed quickly, with minimal disruption, and improved chances for recovery.
As more claim processing is delegated to third-party administrators, error rates have hovered between one and three percent. For large health plans, these percentages translate to substantial sums, making diligent auditing essential. Even with service agreements that include performance guarantees, only independent audits can verify that standards are being met. The push for more oversight is fueled by ever-increasing health care costs that rarely slow. It makes designing claim systems for audit-readiness and accuracy more important than ever. It’s a win-win situation for all parties in the long run.
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