Since self-funded corporate health plans were introduced, regulations have required periodic audits. Initially, medical claim and pharmacy benefit manager audits used a random sample method. While this approach was an improvement over no auditing at all and revealed some systemic errors, it inevitably missed many mistakes. Advances in technology have transformed the process: modern audits now routinely review 100 percent of claims, dramatically increasing accuracy. This detailed approach uncovers all errors, equipping plan managers with more reliable data to oversee claim administrators.
The introduction of the 100-percent claims audit in the 1990s revolutionized the sector and established a new benchmark for what could be detected and corrected without demanding more time or money from companies. Enhanced computers and software now process claims faster and with superior precision, examining each claim for correctness and conformity with plan rules. Even small errors that previously went unnoticed are quickly identified, providing more opportunities for timely corrections. The improved accuracy has significantly raised the value of claim auditing got health plan sponsors.
There is a clear link between audit accuracy and the efficiency of the benefit plan being reviewed. As 100-percent audits identify and correct errors, plan performance improves measurably. Early skepticism about this approach has faded as its advantages became obvious. Electronic review of every claim simply delivers a level of accuracy that random samples cannot match. This method also assures plan members of a fair allocation of resources, guaranteeing everyone receives the services promised under the plan. It also helps plan meet their fiduciary responsibilities are they are more closely managed.
Most 100-percent audit processes incorporate a manual review following the electronic identification of inaccuracies. This guarantees every claim receives the most complete assessment, while reducing the time required from plan managers. Today’s approach is far less demanding than the lengthy process of reviewing random sample findings. It represents a genuine advance, ushering in a new era of improved plan performance. Any self-funded corporate benefits plan—including medical, dental, and vision care—can benefit from a 100-percent audit. Getting it right with claim payments benefits every plan.