Timing Matters in Medical Claim Audits Pittsburgh

The role of medical claim auditors is to assist clients, typically self-funded medical and ******cy plans, in identifying errors. These mistakes can arise from human error or systemic issues, but either way, they can accumulate quickly, especially in larger plans and during unexpected events like the recent COVID-19 pandemic. With significant financial implications at stake, even the performance guarantees from leading third-party claim administrators may not suffice. Conducting a comprehensive audit that scrutinizes every claim payment is the most effective approach, and it's the most efficient.

Engaging an independent auditing firm for your claim review can enhance the likelihood of flagging all errors and implementing systemic improvements. Specialist firms bring knowledge and a fresh perspective to your claim data, knowing where to focus their efforts. Their experience with similar plans equips them to provide valuable insights into yours. Utilizing both thorough and efficient proprietary software makes a significant impact, as established audit firms have reviewed all administrators, making their expertise invaluable. It also accelerates the process, as their systems are already in place.

If your company employs a large audit firm with a wide array of services, it's worth reconsidering your approach to claim reviews. Specialist claim auditors possess in-depth experience from the health plan sector that gives them a deeper understanding of the specific needs and opportunities related to claim audits. Independent firms prioritize your company's interests and are committed to uncovering every error that may affect your members' service and your financial outcomes. In contrast, larger firms with multiple interests might not approach the task similarly, potentially influencing the results.

In addition to auditing medical plans, it's important to include the ******cy plan. There are numerous opportunities for correcting errors. Formularies outline what is covered, and auditors can flag mistakes when brand-name drugs are mistakenly dispensed when generics are available. Even well-meaning prescribers can make errors, so you must remind them and your claim processor to adhere strictly to the formulary guidelines. As annual medical services and medication costs continue to rise, audits become increasingly valuable and can be conducted continuously to monitor payments.

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