For any employer-sponsored health plan, auditing claims is the best way to assure payment integrity and goes for medical, pharmacy, and dental claims. Claim processors make performance guarantees that many meet, but even error rates of a couple of percents add up. A picture quickly emerges when a comprehensive audit electronically reviews 100 percent of claims with highly accurate software. The opportunities for improvements and recovery of payments made in error are clear, and it's a plan management tool that's unmatched in value. Well-run plans audit often or continuously monitored.  

There has been a trend toward more frequent auditing because of its many advantages, and the coronavirus pandemic brought them into clear focus. Many plans saw a massive spike in utilization and astronomical charges for some services. Those that had an expert auditor in the wings ready to go were much better able to manage a crisis. Plan sponsors auditing less frequently, or without auditor relationships, were left scrambling. When things get out of control with medical charges, million-dollar problems can develop and are tough to correct – avoiding them is always the wiser approach. 

Claim audits today are significantly more accurate and less time-consuming than they were only a few years ago. They're driven by continuous technological advances and the entry into the field of people who have experience with large health plans. Insurance carriers commonly process claims for employer-funded plans and understanding their system configuration helps. The best audit software is optimized by the carrier and considers its unique attributes. When claim reviews are accurate, their value is apparent. Auditing is more about plan management than compliance.

The final primary consideration is the audit firm you select. Boutique firms specializing in claim audits have particular expertise and can go beyond what some of the mega firms offer. Auditing is generally about taxes and compliance, and claim reviews have additional dimensions. While they are about money, in the end, medical understanding is needed for claim reviews. Claim auditing is more complex in some ways than financial auditing, and the expertise in health claims is invaluable. Even if your company or organization has a relationship with a generalist auditor, think twice about the claim review.