Much attention is rightfully paid to rising health care and prescription medicine costs. Each one has unique dynamics that drive the increases, and auditing claims uniquely is required. Medical service and prescription medicine cost spiked during the COVID-19 pandemic, and large employers sponsoring benefits plans took a hit. Untangling what happened and whether or not any of it is recoverable has fallen to auditors working in the aftermath. It demonstrates the need for oversight, ideally not long after the claims are paid. Trying to recover overcharges too far in arrears makes it much more complicated.
One factor that's helped sponsors considerably is the 100-percent method widely used in claim audits today. Advanced technology allows every claim to be reviewed against numerous checkpoints. The more sophisticated audits flag many more errors and identify opportunities to recover funds paid in error. It's also crucial for plan sponsors to be activists in overseeing recoveries. If third-party administrators outsource the function to collection agencies, they retain a cut of the proceeds. It means the processor is paid after making a mistake, and then another vendor is paid to correct the error.
Medical claims auditing focuses on services provided, whether any have been duplicated, and the fees charged versus plan maximum and reasonable and customary. Lab tests are a particular area of focus in many audits, and National Correct Coding Standards provide a guide. Duplicate or overlapping tests are a consideration, and better auditors know how to identify them quickly. Audit reports give a clear snapshot of claim processing accuracy and point to opportunities to recover overpayments. Helping processors make systemic fixes should be the natural secondary benefit of an audit.
The medical claims audits focus on a specific set of checkpoints. They need to review thousands of claims quickly and check for doctor fees above reasonable and customary. Also, lab test charges need to be analyzed and compared against National Correct Coding standards. Payments above or outside of standard rates need to be questioned and recovered. Redundant test pairs are a significant issue in some cases, and they're hard to ask about until plan sponsors have information. Better claim auditors are known for their thorough and easy-to-read reports with clear, actionable information.
Auditing pharmacy claims is an entirely different set of circumstances. Name-brands improperly dispensed over generics are the most common catch, but there are others. Quantities and refill frequencies also can be issues. In all cases, auditors with advanced software can catch all the problems as they review each paid claim for dozens of checkpoints. For anyone only familiar with random sample audits, seeing the results of a 100-percent review for the first time can be an eye-opener. When the reports are detailed yet easy to read, it puts every issue in the spotlight and catches them in every claim paid.
