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Essential Oversight for Employer Health Plans
Essential Oversight for Employer Health Plans
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tfgpartners
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Oct 06, 2024
10:38 PM
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Managing employee medical and prescription plans is a complex and important task for large employers, as it involves a significant amount of money and impacts the well-being of their workforce. As a result, a healthcare audit plays a crucial role in ensuring the effective management of these plans. By reviewing and overseeing claim payments, these auditing services provide opportunities for cost management and contribute to improving member service and ensuring equal treatment for all plan members. Employers should be clear about their goals and objectives when engaging with auditors.
While auditors offer recommendations based on their experience, employers can also benefit from expanding the scope of services by asking their own questions and providing insights into their unique plan provisions. With the advancement of technology, electronic claim reviews have made it possible to thoroughly screen claim payments for thousands of variables and consider a plan's special provisions. Additionally, working consistently with the same auditor allows for easy comparison of current and past audits, giving employers the added value of identifying error patterns and cost trends early on.
Historically, auditing was seen as a regulatory and compliance requirement for self-funded plans, often conducted with random sampling to meet government requirements. However, with the evolution of software and systems, the auditing process has undergone a transformation. System upgrades have made it possible to review 100 percent of claims with less effort than previously required. This shift has turned audits into opportunities for plan management and added value beyond mere compliance. The trend of continuous upgrades further underscores the evolving nature of health plan auditing.
Employers can also consider adding a second layer of oversight to complement the data provided by third-party administrators or pharmacy benefit managers. Furthermore, independent auditors bring a wealth of experience from working with other plans, which can lead to well-informed inquiries in the employer's specific case. In summary, health plan auditing services are essential for effectively managing employee medical and prescription plans. Employers can maximize the benefits of these services by actively engaging with auditors, leveraging technology for thorough reviews, and considering additional layers of oversight to optimize their plan management. It saves money and improves member service.
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