There are few corporate services you can engage that put dollars back into your budget, but medical claims auditing can be one of them. For large employers self-funding their benefits plans, finding overpayments and other claim payment irregularities adds up to big money. For example, it's routine for a medical and pharmacy claim review to flag recoverable errors adding up to four times the audit's price. Any plan sponsor that audits only for regulatory and compliance is missing a significant opportunity. Auditing more frequently makes it easier to keep plans on track and control claim costs.

Both for-profit corporations and large nonprofits self-fund their medical and prescription plans. Then it's common to outsource the claim administration. It's a unique system where a company makes payments on behalf of another – controlling its purse strings to an extent. Many processors do an excellent job and keep error rates low, but there is always room for improvement. Even small errors are costly with the high price of medical services and medications today. Today's audits can find error patterns and single mistakes, which add up. Plans that recover overpayments do better.

Since the pandemic, there has also been movement among self-funded plans and their outsourced claim processors. If you soon switch your third-party administrator or pharmacy benefit manager, schedule an implementation audit after three months. Hearing an outside auditor's opinion at the 90-day mark is insightful. The system setup has much to do with claim payment accuracy, and implementation auditing provides an assist. Every plan has hundreds of provisions, many of them unique. Ensuring they are in the claim administration system is vital for member service and cost management.

When audits are set up, it's okay to let auditors make many decisions because they have experience and know where to look. But it's also okay to ask questions and make requests. If you have earlier audit reports, share them and see if they can be improved with the subsequent claim review. A claim audit aims to generate actionable data that prevent future errors and creates recovery opportunities for past ones. The financial opportunities are significant and well-run plans also serve members better. Get started today if you last audited your self-funded plan a while ago.