The Post-Pandemic Claim Auditing Landscape

The coronavirus pandemic profoundly impacted the healthcare payment landscape. Large employers self-funding their plans have increasingly turned to specialized healthcare audit services to assess and report on their experiences during the pandemic thoroughly. However, it's crucial to note that providers, such as hospitals and medical practices, can also reap the benefits of these claim audits. It is because issues like underbilling or incorrect coding can result in undercharges, and therefore, auditing and validating the accuracy of billing is essential to ensure proper payment every time.

During the pandemic, numerous extraordinary overcharges garnered widespread attention. Beyond these headline-making incidents, the entire healthcare system faced intense pressure due to a surge in utilization and the resultant challenges in keeping up. Even in more typical scenarios, the exceptional increase in volume correlated with a heightened risk of errors. Therefore, payers and providers must be vigilant in identifying patterns of errors, particularly those stemming from incorrect coding or other mistakes. Detecting and rectifying these issues represents a significant opportunity, especially within today's systems, where all claims are subject to review and correction.

Some providers, including medical practices, are actively engaging in claim audits, similar to payers, to ensure the utmost accuracy in billing. Improper coding can be a significant factor for them, and errors made by staff members can lead to substantial losses. On the payer side, plan sponsors are responsible for overseeing that services are provided in accordance with plan rules and that payments are made. Their fiduciary duties necessitate the proper allocation of funds and equitable treatment of all members, who heavily rely on accurate and consistent claim payments, especially in plans with high deductible options.

It's important to note that not all claim auditors possess the same capabilities, and selecting one with unique expertise can yield significant benefits. Smaller independent firms without conflicting allegiances are often preferable, as they prioritize your interests and are not clouded by competing agendas. While larger, more generalized auditors are undoubtedly capable, they may not always offer specialized expertise. As the complexities of both claims and the medical services they cover continue to evolve, the importance of thorough auditing cannot be overstated – double-checking always helps.