Medical and pharmacy claim audits can typically find errors among 2 to 5 percent of total claims, which can represent significant dollars for self-funded plan sponsors. Comprehensive independent claim audits not only confirm claims are correctly processed, they can also aid in the recovery of over payments, evaluate quality assurance and monitor a third party administrator’s (TPAs) performance. While health claims audits can be conducted at any time, these four circumstances may indicate your plan is due for a check-in.
- Employee complaints
If you’ve heard rumblings of dissatisfaction among employees with the execution of your plan, a claims audit may be in order. Your employees are your most valuable asset, and their happiness with their benefits is key to strong employee retention rates. You put a lot of stock in your plan design, and failed execution results in lost
value. A post-implementation audit may reveal findings like incorrect application of an updated copay for specialist visits or weaknesses in the TPA’s duplicate claim logic. - It's been a while
Employers assume fiscal responsibility for the plans they sponsor. Practice due diligence and perform an audit every few years to make sure your plan is operating smoothly and accurately, even if no major changes have been made. Errors and inefficiencies may be inconspicuous enough to remain undetected in the day-to-day operations of your plan but could rack up a notable chunk of unnecessary costs in the long run. - Recent changes to your benefit plan
An updated plan warrants an updated audit. Implementing a new plan without examining its performance is like buying a new car without a test drive – you don’t know what’s really happening under the hood. If you have gone through some major changes in your benefit plans, make sure that everything is running smoothly, and claims are processed accordingly. - Concerns about plan administration
If you suspect your TPA is falling short of their obligations, an independent claims audit can review their performance and indicate where adjustments need to be made. While your TPA may conduct internal audits, an outside audit can provide a more thorough view and identify liabilities and unnecessary costs that may have otherwise flown under the radar.
If you’re interested in learning more about a medical claims audit, talk with your Bukaty benefits consultant.
