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As Medical Costs Rise, Audit Claims



Overcharges are the tip of the iceberg in medical billing errors that cost millions of dollars annually, underscoring the critical need for comprehensive oversight through medical claim auditing services. These audits serve as a vital safeguard, identifying potential overcharges, recovering incorrect payments, and ensuring equitable treatment for all members. Additionally, they provide invaluable data for negotiating rates with providers and allow for timely adjustments during unexpected events. Health plan auditing is increasingly utilized by large employers that self-fund their plans. 


As claim payments have transitioned to third-party processors, audits have become a reliable backstop. While insurance carriers that function as third-party administrators maintain a high degree of accuracy and keep error rates low, the substantial dollar amounts involved make even a small percentage of errors impactful to a sponsor's bottom line. Audits play a crucial role in reviewing claim payments, flagging potential overcharges or incorrect bills paid, and facilitating the recovery of financial resources. There's also the option of having auditors check claims continuously and report findings monthly.


Careful plan management, coupled with frequent auditing, has become a standard practice for many sponsors, enabling them to effectively manage costs and ensure the integrity of their health plans. Furthermore, medical practices and health care providers also stand to benefit from audits, as they provide a means to ensure accurate coding and billing for all services rendered. Health plan claims and payments are necessary and complex and demand oversight to ensure accuracy and fairness. Understanding where cost increases occur is instructive as it assists in future negotiations about rates and fees. 


Keeping audit software running in the background has become an increasingly common practice. The cost of the service is almost always less than the funds it helps recover. Concerns about refunds are minimized by promptly identifying and rectifying mistakes, and negotiations become more straightforward. Auditing plans infrequently and attempting to recover overpayments from past years can contribute to a complex and protracted negotiation process. Therefore, continuous monitoring and auditing have emerged as crucial tools for maintaining the fiscal integrity of self-funded health plans.


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