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The coronavirus pandemic prompted extensive discussions on healthcare costs for many reasons. As a result, healthcare auditing companies have been called on to review claims and give insight into increased costs. Depending on the location where plan members were treated, the billed prices for similar items varied significantly. In this complex landscape, audits have played a pivotal role in unraveling details, shedding light on the events, and providing essential insights to prepare for similar future occurrences, especially for large employers with self-funded medical and pharmacy plans.
Claim auditors with unique expertise and proprietary software have emerged as essential allies in this landscape. They conduct comprehensive reviews, meticulously examining 100% of claim payments against dozens or even hundreds of details. The post-audit analysis has revealed staggering charges and cost trends in certain areas while flagging mistakes and irregularities. Sponsors receive detailed reports on their plan's performance, empowering in-house staff to collaborate effectively with and oversee third-party administrators and pharmacy benefit managers—nothing replaces factual data in hand.
The review process for medical claims entails scrutinizing many claims to identify anomalies, including doctor fees exceeding reasonable and customary rates, and analyzing lab test charges vis-à-vis National Correct Coding standards. Furthermore, audits focus on questioning and recovering payments that exceed standard rates and identifying redundant test pairs, which are often challenging to address without the insights provided by the audit reports. The thorough and comprehensible reports produced by adept claim auditors equip sponsors to take actionable steps based on the findings.
The checkpoints in pharmacy claims audits are equally extensive. Each claim is reviewed against the formulary to ascertain compliance with using generics over name brands, where applicable. The audit process also encompasses double-checking refill quantities to ensure adherence to limits, as exceeding these limits presents a notable area of concern in utilization reviews. Providers, unbeknownst to them, might be making errors, and only through these audits can such errors be effectively identified and addressed. Catching even small mistakes adds up impressively over time.
Claim auditors with unique expertise and proprietary software have emerged as essential allies in this landscape. They conduct comprehensive reviews, meticulously examining 100% of claim payments against dozens or even hundreds of details. The post-audit analysis has revealed staggering charges and cost trends in certain areas while flagging mistakes and irregularities. Sponsors receive detailed reports on their plan's performance, empowering in-house staff to collaborate effectively with and oversee third-party administrators and pharmacy benefit managers—nothing replaces factual data in hand.
The review process for medical claims entails scrutinizing many claims to identify anomalies, including doctor fees exceeding reasonable and customary rates, and analyzing lab test charges vis-à-vis National Correct Coding standards. Furthermore, audits focus on questioning and recovering payments that exceed standard rates and identifying redundant test pairs, which are often challenging to address without the insights provided by the audit reports. The thorough and comprehensible reports produced by adept claim auditors equip sponsors to take actionable steps based on the findings.
The checkpoints in pharmacy claims audits are equally extensive. Each claim is reviewed against the formulary to ascertain compliance with using generics over name brands, where applicable. The audit process also encompasses double-checking refill quantities to ensure adherence to limits, as exceeding these limits presents a notable area of concern in utilization reviews. Providers, unbeknownst to them, might be making errors, and only through these audits can such errors be effectively identified and addressed. Catching even small mistakes adds up impressively over time.