With healthcare costs rising year after year—and the added challenges highlighted by the coronavirus pandemic—managing expenses requires a multifaceted approach. Accurate claims payments don’t just affect the bottom line; they’re also a matter of fairness for plan members, ensuring everyone receives equal treatment. Sticking to your plan’s provisions helps improve performance, control costs, and provide better service. However, without regular audits and payment reviews, sponsors working with outside processors often rely solely on the reports those processors provide.
Choosing the right claims auditor and building a relationship can deliver significant benefits. Over time, auditors become familiar with the specifics of your plan and provide consistent, reliable reports. This makes it easier to compare different years or periods, spot trends in costs, error rates, and other claim payment details. If you’re switching to a new third-party administrator or pharmacy benefit manager, it’s smart to do an implementation audit. Giving the new partner time to set up your plan correctly is crucial for ensuring claims are paid accurately. It’s a good idea to review their work after a few months.
Continuous claim reviews are a newer, fast-growing approach that keeps a constant eye on payments. Modern audit software runs in the background and provides monthly reports on any discrepancies or trends it finds. Ongoing oversight gives employer health plans leverage and helps keep processors accountable. The cost is usually far less than the amount recovered from catching errors. By staying on top of claim processing and payments, plans can avoid issues that might otherwise require costly fixes later. It’s a proactive, effective way to keep costs in check and maintain smooth operations.Statistics: Posted by TFG Partners, LLC — Wed Dec 24, 2025 9:34 am
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