Every year, claim auditors deliver significant value to employer-funded health plans, which are their main clients. Running a medical and Rx audit helps the bottom line by typically identifying recoverable overpayments that can amount to two to four times the cost of the audit itself. Beyond immediate financial recoveries, these audits often result in system improvements that minimize future errors, amplifying their overall impact. Medical and pharmacy benefit plan sponsors stand to benefit greatly from routine audits or ongoing monitoring of claims with the thorough reports each produces.
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Recently, a large employer has taken legal action against its third-party claim processor, highlighting significant cases of alleged overpayments and overcharges. The issues outlined in this lawsuit are likely the same ones that audits spot during their reviews. The complexity of medical billing poses challenges, and accurately paying claims according to plan provisions requires attention. Even with exceptionally low error rates, audits can uncover substantial recoveries by identifying mistakes that are often hidden within the intricacies of complex claims. That’s why having knowledgeable specialist auditors is crucial.
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