Oversight for Employee Benefit Plan Claims

Oversight for Employee Benefit Plan Claims

Healthcare costs in the United States continue to rise yearly, and the recent coronavirus pandemic added a significant additional burden. The situation increased the financial strain on self-funded company plans; however, healthcare audit services provided valuable assistance. In addition to identifying mistakes and irregularities during audits, continuous monitoring services offer substantial advantages by utilizing the same audit software to review claims in real time. Enhanced oversight allows in-house plan managers to manage third-party claim administrators (TPAs) effectively.

Many professionals involved in health plan management are familiar with accounts of exorbitant overcharges related to coronavirus testing and treatment. Self-funded plans with continuous monitoring from the start were better equipped to identify questionable billing practices early on. In contrast, companies relying on retrospective audits had to reassess and negotiate to reclaim overpayments or dispute excessive charges. Plan managers equipped with real-time data found themselves much more capable of navigating these challenges, providing better service, and controlling costs.

Originally, audits of self-funded plans aimed to ensure compliance with federal and sometimes state regulations. However, they have evolved into more than just a compliance task. Auditing and monitoring have become crucial with the substantial amounts spent on medical benefits and the prevalence of overcharges and errors. They now function as strategic management tools that enhance plan performance while delivering cost savings. Reviewing 100% of claim payments—considered the gold standard for accuracy—has ushered in a new era of precision and value in auditing.

Technological advancements have enhanced medical claim auditing and monitoring and raised expectations for improved accuracy. As a result, in-house plan managers are increasingly called upon to oversee TPAs, provide timely reports on claim payments, and offer detailed explanations for any unexpected discrepancies. These requirements are supported by continuous monitoring or frequent audits that scrutinize all claims. The potential to prevent future errors and recover past overpayments often makes the costs for auditing and monitoring services budget-neutral or even beneficial.