Each year naturally brings more experience with health plan claims auditing, showing time and again that reviewing payments soon after they are made helps. The best medical claim auditors have sophisticated software and particular expertise in the field. The results their reviews generate often outpace what's available from larger generalist firms. Their unique expertise helps them understand where the potential for mistakes lies, how to detect them, and how to report them in valuable ways. As a result, they are much more able to stop large patterns of errors and show plans on how to make recoveries.

When employer-funded plans contract third-party administrators and pharmacy benefit managers, they allow someone out of house to control cash outlays. It's a significant responsibility and one that large health carriers take on with networks and negotiated price agreements they can share with plan sponsors. All have systems to pay claims according to specific criteria they have established. But most employer plans may deviate from the carrier's rules and require specificity in their claim payments and processing. It's where the hang-ups can occur, and auditors can find them.

Allowing mistakes to sit for months or years and trying to recover overpayments and correct errors in arrears is more complicated. People with the most experience in the field recommend frequent auditing or continuous monitoring using the audit software. Either will find and flag errors in real-time, making a recovery less complicated. Reconstructing events long in the past is more challenging and can disrupt provider cash flows when refunds are requested. When you ask within the years when the errors occurred, making the recoveries easier and faster, and the negotiations are often easier.

Today's claim audits nearly continually review 100 percent of claims paid. Anyone advising against a complete review goes against the flow and may not have advanced claims review systems. The miracle of advanced software is its ability to run quick checks that get close to the final results needed. Human oversight of the initial results by trained auditors is a quick process, not requiring staff time from anyone at the client company. The quality of audit reports also matters, and there is a trend toward making them detailed but not overly complex. When the data is clear, it is easier to act on promptly.