How often should benefit plan claims be audited is a common question among those responsible for managing plans, especially self-funded ones. It varies because no two plans are alike, but medical claims auditing is in increasing demand, and audits are occurring more frequently. It's likely because sponsors have realized the value in running oversight, especially as most have outsourced the processing to third-party administrators and pharmacy benefit managers. With thousands of dollars on the line each day, it's incumbent on sponsors to audit so incorrect payments are recovered.

One of the most significant recent developments in the field is continuous monitoring. It runs the audit software in real-time to detect and flag irregularities. Mistakes come in many forms, and detecting and eradicating as many as possible keeps plans running better. It's impossible to manage costs without accurate claim payments because they're where it's possible to affect the expenses. When an event like the coronavirus pandemic turns things upside down, plans with well-managed claims processing capabilities can stay on track more effectively and serve their members better.

People with years of experience managing health plans may recall the initial random sample audits mandated by compliance requirements. After an electronic review, they required a fair amount of human oversight, which ate up staff time and resources. Today, the electronic portion of an audit checks all claims paid for hundreds of data points. Comparing them to earlier random samples is almost unfair because today's accuracy is so much better. It's why plans now view auditing as a management tool rather than a compliance issue. It has helped with containment and better reporting.

The trend towards outsourcing claim processing accelerated just as audit technology improved, which was serendipitous. When claim payments originated in-house, it was easier for sponsors to keep tabs on accuracy because they controlled all of the data. With third-party administrators and pharmacy benefit managers in control, audits are the way to conduct oversight. With expectations for cost containment against rising healthcare services prices, accurate claim processing becomes ever more critical. Anyone managing a health or pharmacy plan today will tell you about the financial pressure.