Why Does Benefit Claim Auditing Matter? Philadelphia

The increasing costs of healthcare and prescription medicine have drawn significant attention, especially during the COVID-19 pandemic. Large employers providing benefits plans have been adversely impacted as medical service and prescription medicine costs surged. Healthcare auditing companies have stepped in to review claims and unravel the reasons behind the cost spikes -- and to facilitate recovery of overcharges. Timely oversight of claims processing is crucial, as attempting to rectify overpayments retroactively complicates the process. Sponsors have benefited significantly from the widespread use of the 100-percent method in claim audits. 

Advanced technology enables comprehensive reviews of each claim against multiple criteria, leading to the detection of more errors and the identification of opportunities to reclaim erroneous payments. Sponsors' active involvement in overseeing recoveries is essential, as outsourcing this function to collection agencies may result in the agency retaining a portion of the recovered funds, effectively incentivizing errors. Medical claims audits primarily focus on assessing provided services, identifying any duplications, and evaluating fees in comparison to plan maximums and reasonable and customary charges. Auditors often pay particular attention to lab tests, using the National Correct Coding Standards as a reference. 

Duplicate or overlapping tests are scrutinized, and proficient auditors can swiftly recognize them. Audit reports offer a clear overview of claim processing accuracy and highlight opportunities for recovering overpayments. A secondary benefit of audits is the potential for facilitating systemic improvements in claim processing. These audits are centered on examining thousands of claims efficiently, with a focus on identifying doctor fees that exceed reasonable and customary charges and analyzing lab test charges against established standards. Payments that exceed standard rates or fall outside of the standard parameters require scrutiny and potential recovery. 

The detection of redundant test pairs, which can be challenging without pertinent information from plan sponsors, is another key focus. Skilled claim auditors are recognized for producing comprehensive, easily understandable reports that offer actionable insights. ******cy claims audits present a distinct set of challenges. The most common issues include the improper dispensing of name-brand medications over generics and concerns related to quantities and refill frequencies. Auditors equipped with advanced software can efficiently identify these issues as they review each paid claim across multiple checkpoints. For those accustomed to random sample audits, the detailed and comprehensible reports from a 100-percent review often present a new perspective, shedding light on every issue and identifying problems across all paid claims.

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