Improve Health Plan Performance with Audits

Health plans play a critical role in the lives of their members, which is why they strive to meet service

and financial goals. A key area of focus is reports from medical claim auditors whose work reviews

various performance factors. Achieving financial targets is not enough if the quality of member service

falters, and the reverse is also true. Well-managed health plans excel in both areas and are committed

to ongoing improvement. While auditing is often viewed primarily to recover overpayments and

capitalize on financial opportunities, numerous other benefits arise from it as well.

One noticeable trend is that plans that undergo rigorous audits tend to experience fewer discrepancies

in their claims. When speaking to auditors, many emphasize that implementing system corrections is an

opportunity for improvement. These corrections can lead to savings by preventing recurring patterns of

errors. Accurately loading plan details into auditing systems requires attention to detail and ensures

electronic reviews yield exact outcomes from the onset. Certain moments, such as immediately after

adopting a new claim processing system, can be particularly advantageous for an in-depth audit.

In recent years, advancements in software and technology have transformed claim auditing. The

contrast between reports generated today and those from a decade or more ago is striking. Modern

health plans now routinely conduct follow-up reviews to discover areas for improvement and recover

any overpayments. Situations like the recent coronavirus pandemic further underscore the importance

of audits. These reviews can yield valuable insights on both medical and financial fronts, addressing the

increasing complexities involved in claim processing, especially with more sophisticated treatments.

Additionally, regular oversight supports fiduciary responsibilities and ensures accountability. As

expectations around accuracy rise year after year, the frequency of claims auditing is also on the rise.

While satisfying regulatory requirements is crucial, it often isn't the primary motivation behind

conducting these audits. Many audits reveal potential savings that can amount to four times their cost,

creating a compelling incentive for health plans to assess their performance. As profit margins tighten

and members seek competitive rates, identifying and correcting errors has never been more essential.