Print Page - When to Audit Healthcare Claim Payments

Title: When to Audit Healthcare Claim Payments
Post by: TFGPartner on Jun 18, 2025, 07:51 AM

Most employer-funded benefit plans conduct annual audits, if not more frequently, due to the value of regularly reviewing claims. If you are managing a plan in-house and scheduling medical claim auditing services (https://www.tfgpartners.com/medical-claim-audits/), it's wise to act sooner rather than later. A prime opportunity to initiate an audit is just before you begin planning and budgeting for the upcoming year. In addition to identifying recoverable errors, an audit also provides data to analyze against the reports generated by your claims administrator. Having clarity on the most recent year's performance is essential for effective budgeting and forecasting.

One of the advantages of claim audits is the flexibility to include specific requests and inquiries in the review process. Experienced auditors personalize their examinations to focus on the elements that are most significant to you. Ideally, these professionals have extensive field. Their ability to target areas where errors commonly occur in other plans enhances the audit's effectiveness. In addition, auditing after extraordinary events, such as the coronavirus pandemic, is particularly valuable. You identify mistakes to correct and uncover details that go beyond what an administrator reports.

The pandemic created unique challenges for healthcare plans, making it essential to address any overpayments and complications that arose. Today's audits are designed to review 100 percent of claims, with the majority processed quickly and electronically. Human oversight plays a role in setting up systems and reviewing final reports. Having consistent auditors conduct ongoing oversight enables you to compare reports across different audit periods for deeper insights. An independent review can verify the self-reported data from your claim administrator, which is critical for ensuring accuracy.

Although error rates are low, the expenses involved justify a thorough examination. The evolution of audit systems and software has ushered in a new phase for claim reviews. Unlike in the past, where recovery of only large groups of repeated errors was possible, today's processes allow for individual claim recoveries when the sums involved are substantial. Recognizing past mistakes and rectifying systems can prevent future errors. This approach leads to exceptional accuracy in managing plans, ensuring that members receive fair and consistent claim payments, which benefits everyone involved.

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