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Market Research Group

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Claim Audits Answer Many Questions



Gaining insight into how employee benefit programs are performing, especially medical and pharmacy plans, is essential for the companies sponsoring them. Running a healthcare audit and having the review check all the required things, plus double-check your areas of concern, is one of the most effective ways to answer your questions. Because nearly all employer-sponsored plans these days use outsourced claims processing, having auditors look routinely is wise. You can compare their findings with what your claim administrator and pharmacy benefits manage self-report. It's intelligent to have routine oversight.


Technology and its increasing intelligence have revolutionized the claims auditing field. Electronic reviews today can check every claim for many variables and generate impressive reports. Much depends on the experience and insight of the people building and running the systems, but the capabilities they can build in an increase every year. When you work with the same auditors over time and can use their periodic reports for apples-to-apples comparisons, you begin to have excellent oversight of your company's plan. Also, specialist auditors who work on claims as a specialty are more insightful.


Back in the days of random sampling as the only option, audits were random samples requiring considering staff time to review. They could draw general conclusions and identify large, repeating error patterns. However, there was little ability to find individual errors, which the current technology has shown to add to significant numbers. Now, as all claims are checked, a much clearer picture of plan performance emerges. Audits can also be highly customized and, if run twice, will produce the same reliable results because they check everything. With random samples, things were never the same way twice.


Pre-audit meetings are one of the most significant opportunities in the process. They provide a forum to bring your questions and ensure the audit team has your priorities in mind. If you find out things you need to know, the value of the audit increases meaningfully. You'll also have oversight data for meaningful conversations about performance improvements with your outsourced claim administrator. Every year, medical and pharmacy billing evolves. Even the best and most efficient processors can miss things or have things fall through the cracks. When you catch and flag the mistakes, it always helps.


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