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Benefit Plan Claims in Need of a Review?



Keeping employee benefit plans running well is imperative for companies that self-fund them. It's the same for large nonprofit employers with similar benefit setups. Led by medical claim auditing, reviewing all benefit plan payments is imperative. Oversight is crucial because claim administrators make the payments and, therefore, have control of your company's checkbook. Outsourced processors are generally large health plans with sophisticated infrastructure. But they're set up to process claims in their own way, and your plan may have unique provisions. Auditors help you see that your rules are followed.


An opportunity exists if you've had variations in expenses and budgets outside the expected parameters and are only auditing periodically as required for compliance. When you begin to audit more often (and more thoroughly), you'll have details and explanations for the cost variances. Your outsourced claim administrator will self-report, but the independent audit review confirms their accuracy. With the dollar amounts on the line in medical and pharmacy claims, keeping an eye on payments and any irregularities is imperative. The most challenging thing is waiting until you have a million-dollar problem.


C-suite executives who are called on to discuss quarterly earnings reports need backup and detail when there are expense variations. Given the cost exposures of medical and pharmacy plans for large employee groups, it's essential to have factual data. It's another reason to audit claim payments routinely and use a responsive audit firm that produces thorough reports. Given today's systems, you can pose any question about your payments for scrutiny, and auditors can deliver answers. It's extraordinarily helpful insight and oversight when you have an outsourced claims administrator.


It's also trending to have your claims audited continuously with frequent reports to keep watch on every detail. Even small things add to significant sums, given the price of medical services and medicines. There is no substitute for oversight and management, and when you're detached from the process and using a third party, running an independent review is the best way to double-check. Every plan benefits from closer management, and members are served better when payments are accurate. You may begin frequent auditing with cost containment support in mind, but you'll find it has many benefits in the long run.

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