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Setting Up a Smoother Medical Claims Audit

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    When a health care claim processing system is set up, building it with an eye to simplicity and ease of auditing is a wise idea. With medical claims auditing of value to providers and heal plans alike, it's becoming a more frequently used management tool. Therefore, having a more accessible system for audits makes sense. Accurate coding is often at the heart of medical claim errors. It costs plans extra money and may also deprive providers of earned revenue. It's one of the factors most of interest to auditors and one that has a significant potential for financial returns. Accuracy from the beginning helps everyone.

    Given the prices for medical services and continuing strain on budgets, it's no surprise that medical practices and health plans benefit from accuracy. While some have the staff needed to handle some claim reviews internally, it's almost always best to bring in a pro from outside. It's a practice long used by health plans self-funded by large employers. They need to double-check the accuracy of third-party claim administrators. With large numbers on the line and auditors' ability to flag recoverable errors, there's a trend to audit more often. Some even monitor their claim payments continuously.

    Technological advance in audit software has transformed the process over the past ten to twenty years. Random sampling has given way to 100-percent reviews that are possible now because of system improvements. They've ushered in a new era of accuracy and reporting. Each claim paid can be checked against hundreds of data points to give a clear picture of actual results. Sponsors and medical practices now commonly audit much more often than required by federal or state regulations. Keeping tabs on errors (or patterns of errors) lets them be resolved much sooner and with only a little mess to clean up.

    As claim processing has increasingly been outsourced to third-party administrators, the error rates have ranged from one to three percent. For larger plans, the dollars are significant and auditing to keep them well managed is financially wise. Even when TPAs have performance guarantees written into their service agreements, only an independent review can confirm the promises are kept. All of the added steps are driven by continuous increases in health care costs that show signs of slowing down. It's also why setting up for an audit by building an accurate processing system is more vital than ever.