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Are you managing a self-funded corporate or institutional employee medical plan? If so, you're likely familiar with the challenge of delivering excellent services to your plan members while controlling costs. Each claim processed must be precise and align with the coverage parameters. Medical claim audits are valuable partners in overseeing and managing your third-party administrator (TPA). Advanced software and methods provide a crucial layer of assurance regarding accuracy. Errors in claim processing can accumulate quickly and lead to significant financial losses if not identified and addressed.

More self-funded plans now work with auditors who review 100% of claims. Random sampling can't compare to a thorough examination of every dollar spent. In addition to identifying errors, these auditors contribute to setting performance goals for the plan by documenting their findings in detailed audit reports. The presence of accurate oversight positively impacts TPAs as well; having data-backed discussions with in-house plan managers fosters meaningful improvements. While most TPAs offer accuracy guarantees, proper oversight reinforces this promise.

Employees in high-deductible plans also benefit from claim payment reviews since errors impact them as much as they do the plan itself. Improved accuracy in claim payments results in advantages for both parties. Implementing an ongoing monitoring service that utilizes the same auditing software and processes allows plan managers to monitor claim payment performance and catch mistakes or irregularities before they escalate. It is also helpful when upper management seeks answers or when there are increases in costs; having reports and data that explain these figures can be valuable.

With the significant funds involved in medical plans and claim payments, it's clear why there is a push for enhanced accuracy and accountability. What started as a response to regulatory compliance has evolved into a vital management responsibility. Unforeseen circumstances, like the COVID-19 pandemic, which brought unexpected challenges to many plans, further highlight the necessity of precise claim payment oversight. Sudden cost increases can quickly impact balance sheets and quarterly earnings, making the supervision of these financial processes more important than ever.