The Importance of Health Plan Claim Audits
Employers sponsor and self-fund health and benefit plans for various reasons, including financial considerations. The costs of these plans can be substantial and vary widely due to external factors, making oversight such as reviewing claim payments in a medical and Rx audit essential. It's the most effective method of scrutinizing expenditures and ensuring that claim payments adhere to the plan's parameters. Over time, claim auditing has evolved from random sampling to examining 100% of claims. Initially considered a compliance function, it has become a crucial tool for plan sponsors.
The need for oversight has become more critical with outsourcing claim payments and processing to third-party administrators and pharmacy benefit managers, which has removed direct control from the sponsoring company's staff. While this approach offers certain advantages and cost efficiencies, it also creates a need for frequent and thorough auditing. Conducting 100% claim reviews is…
