Conducting a medical and Rx plan audit is an important process that, when properly executed, can produce significant benefits for years. More employer-funded medical and prescription plans are turning to medical claims auditors for oversight and management, intending to improve accuracy and improve performance. To maximize the value of an audit, it must be carefully tailored to the particular details of your plan. There is no universal solution—partnering with a firm that takes a keen interest in your plan’s needs is essential. Beyond the cost savings, improved member service and satisfaction often result.

A key element in a successful claim audit is the electronic review process. Leading audit firms apply advanced, proprietary software that can be tailored to the individual requirements of each plan. Customization is critical—it helps identify systemic errors in claims payments and sets the stage for a thorough, line-by-line evaluation. By methodically checking each claim and flagging discrepancies, the impact of the audit multiplies. A final human review of the electronic results helps eliminate items not suitable for recovery and gives valuable recommendations for system-wide improvements.

Third-party administrators often make performance guarantees, but audits are necessary to verify if those promises are being fulfilled. Solely depending on self-reported data has clear limitations that an audit can overcome. Auditing is especially valuable during periods of rising healthcare costs, such as those seen in the wake of the coronavirus pandemic. When detailed questions arise, audits deliver definitive answers about payments for every service. If overcharges are discovered and recoveries are warranted, detailed audit reports offer a strong basis for negotiations and help assure fair outcomes.

Even if your organization has worked with a large, generalist auditing firm for years, it may be beneficial to consider a specialized firm for your claim review. Boutique auditors bring in-depth expertise, including knowledge of medical coding and the subtleties of healthcare claims, which can greatly improve the quality of their work. While larger firms excel in areas like finance and tax, they may lack the specialized insight required to deeply analyze medical bills and payments. Incorporating specialized medical knowledge greatly improves the ability to detect even slight discrepancies.