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Effective, impartial claim auditing is crucial for optimal management of self-funded health plans for large organizations and corporations. While third-party administrators (TPAs) and pharmacy benefit managers (PBMs) may report their own claims processing accuracy, independent reviews consistently uncover discrepancies. Given the significant financial stakes and rising healthcare costs, identifying both isolated mistakes and recurring problems is essential. All plans gain from comprehensive TPA and PBM auditing services. With TPAs facing regulatory and financial scrutiny, oversight is more important than ever.

Choosing the right claim auditing partner is critical for in-house plan managers. Although many firms offer this service, specialists bring unique expertise and advanced capabilities. Their teams and software handle medical claims daily, achieving unmatched efficiency and accuracy that generalist firms rarely achieve. Top-tier firms also minimize demands on company staff, as they are prepared to manage auditing tasks with minimal oversight. The better firms' 100 percent method for replacing the random sample approach greatly improves accuracy. It also vastly enhances the reliability of the data gathered.

While more firms today can review 100 percent of claims, few can match the accuracy of those who invented the process. Given the complexity of today's plans and providers' ability to bill for a myriad of services, it takes seasoned pros working with the most sophisticated software to audit most effectively. The improved accuracy helps audits and continuous monitoring produce more savings through error correction than the audit services' cost. Optimized oversight programs are structured to catch mistakes early, while they are smaller problems and easier to correct. It also facilitates recovery of overpayments.

Data security has become a top priority, and leading independent facility claims auditors implement extensive safeguards. Their measures include both electronic and physical protections, and they take numerous steps to ensure maximum client security. In-house benefits managers should always ask prospective auditors about their security policies and procedures. Firms differ, so selecting one that aligns with your needs and expectations is crucial. Protecting employees’ health records and personal data is a responsibility and a hallmark of the best claim auditors and how they do their work.