Running a medical and Rx audit to review paid claims has evolved. Initially, the process relied on random samples, which limited the accuracy. However, advancements in technology have enabled the capability to audit every payment, resulting in higher accuracy rates in identifying discrepancies. Audit firms that tailor their services to the details of a plan's covered services can provide the most value. A more general approach may overlook unique aspects pertinent to specific plans, making it essential for auditors to adjust their software to align with both the plan's provisions and the administrator's system.
In plans of varying sizes, even minor errors can accumulate substantial financial losses. Identifying systemic errors is a way to enhance the value derived from an audit. Yet, the importance of systems that capture individual errors cannot be overstated. By targeting all recoverable sums, organizations can experience more significant financial benefits from their auditing efforts. An additional advantage is the reduction in staff time needed for claim audits. With electronic reviews handling the workload, auditors can devote their attention to final checks, which is more efficient than traditional random sampling.
Sophisticated software can further streamline the auditing process by detecting patterns of overuse or misuse of services, such as duplicate tests or services. Addressing these irregularities can prompt healthcare providers to be more strategic with their ordering practices. Often, problems stem from a lack of time or oversight, while others may genuinely be unintentional duplications. Coordinated medical services not only help in containing costs but also ensure that members receive the appropriate level of care without unnecessary testing. Good auditors can ensure it happens as needed.
Additionally, those with high-deductible plans who pay out of pocket benefit from accurate claim management. On the provider side, the use of tailored audits to scrutinize internal billing controls is becoming more common. Incorrect coding or overlooked items can lead to revenue losses. A review by auditors can yield enlightening results, with the potential for improvement varying by practice. For payers, the focus remains on managing billing errors. Organizations overseeing employer-funded plans should consider regular audits as a proactive measure, as they are a budget-friendly approach.