Each year in the U.S., health care costs increase rapidly, and new treatments are introduced with high price tags. The increased expenses keep insurance carriers and employer-funded health plans under pressure, turning to medical claims auditing. Few things are as instructive about costs and experience as doublechecking the claims paid. It's a way to confirm the data reported by third-party administrators and perhaps analyze experience in finer detail. It's essential for more extensive plans with thousands of members and millions of dollars in claims; even small factors add up over time.

Adding oversight can be beneficial for companies and nonprofits trying to manage their claim costs and observe budgets. If there are errors or overpayments, audit findings can often be the basis for recovering them. It makes providers notice that a plan is carefully watching its claim payments and keeps outside administrators on their toes. Members with high deductible coverage also gain from accurate claim payments, ensuring all members' claims are paid evenly. Plans have a fiduciary responsibility to disburse funds accurately for covered services to benefit members. 

Correct coding on providers' invoices is a significant part of accurate billing, and auditors who can cross-check those against plan rules and appropriate treatments can have the most significant impact. Specific code pairs should not exist because they indicate redundant treatment or other irregularities. Keeping providers on notice about a plan's scrutiny of improperly billed items brings more careful billing and fewer attempts to add things that do not belong. Given the complexity of claims, it's a detail-oriented process that requires care and expertise to get it right. You can find smaller specialist audit firms.

Besides medical plans, substantial opportunities for cost savings exist with pharmacy plan audits. They can find discrepancies and dispensing errors such as refills too frequently or name-brands instead of generics. With the high cost of some medicines, there are substantial opportunities. Some medications also qualify for volume discounts and rebates that may be missed but flagged in an audit. It's helpful to give your auditor detailed information before the claim review begins. The accuracy improves when the audit software is front-loaded with specifics and unique aspects of your plan.