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Health Plans: Find Every Payment Made in Error
Health Plans: Find Every Payment Made in Error
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Feb 19, 2025
12:18 AM
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Continuous advancements in medical claim auditing lead to greater opportunities for recovery each year. It's common for employer-funded plans to use audit findings to recover overpayments effectively. Previously, recovery chances were limited to identifying significant systemic errors through random sampling. However, with the capability of reviewing 100 percent of claims during audits, there are now more opportunities to retrieve various overpayments and mistakes. While external claim administrators may boast about low error rates, the rising health costs make it essential to recover all overpayments.
When plans address mistakes and recover overpayments, they let providers and claim administrators know that oversight is in place. This awareness typically results in tighter management that can further reduce error rates. Conversely, plans that maintain less vigilance often end up covering more errors. Continuous monitoring offered by audit firms presents a cost-effective solution, usually leading to recoveries that surpass the service's expenses. Close management of health plan claims yields multiple benefits, with improvements in member services frequently accompanying cost savings over time.
An audit's effectiveness and insights depend on two main factors: the precision of the auditing system and its setup. Each plan is unique, necessitating careful input of specific provisions into the software. Reputable firms dedicate significant time to understanding these details and other nuances, and previous experience with the processors' systems enhances their knowledge base. After the details are meticulously reviewed and the audit executed, the outcome should be straightforward, easy-to-read reports highlighting financial recovery and systemic improvement opportunities.
Today's advancements represent considerable progress, with modern systems transforming claims auditing practices. Random sampling is now often considered outdated and lacking the required level of accuracy. Furthermore, improvements in electronic reviews have diminished the need for extensive staff involvement while increasing accuracy. It creates a win-win situation, as the costs for such services remain budget-friendly and often reveal recoverable errors and overpayments that exceed the price of the audit itself. Unsurprisingly, employer-funded plans are increasingly conducting audits of their claims.
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