Fiduciary Responsibilities for Employer Health Plans

Large dollar amounts in medical and pharmacy plan claims make healthcare audit services a top priority for most plan sponsors. Regulations mandate that plans act in the best interests of their members, and accurately paying claims is vital. It is a significant concern for corporate and nonprofit employers who sponsor their plans as costs continue to rise. With no relief in sight, continuous review of all aspects of the health plan is crucial for effective management. Most experts recommend hiring an independent third-party auditing firm due to several advantages. Your members and the company's bottom line will benefit.

These include their systems, experience, and, most importantly, impartiality. Using an impartial firm reduces susceptibility to biases that could affect internal employees conducting an audit. The firm provides a comprehensive and unbiased review of plan performance, revealing mistakes and system errors that can be corrected. In nearly all cases, audits can result in the recovery of overpayments or claims paid for services not covered. When your plan requests reimbursement for overpayments, it puts providers on notice that you actively conduct oversight – it keeps them on their toes.

Today's auditors can check 100% of claims in their electronic reviews, leading to more accurate results than random sampling. Firms specializing in claim auditing have superior software and systems tailored to the complexities of medical and pharmacy claims. They possess the necessary expertise to meticulously check each claim, with the most significant financial opportunity lying in identifying and rectifying systemic errors. Attend pre-audit meetings with your questions and priorities. This helps customize the claim review so that it produces data that's most useful to your short—and long-term needs.

Many specialist claim auditors have gained valuable experience in the technology departments of significant health carriers, allowing them to set up systems that efficiently check for every detail and present accurate, easy-to-read data. While auditing claims initially stemmed from regulatory requirements, it has evolved into a valuable management tool with significant financial benefits and improved member service. As technology advances, auditors' ability to provide precise results at lower costs will continue to improve. You can also keep the audit software running in the background for monthly reports.