Optimizing Your Claim Audit Timing

TFG Partners
Published on Jul 21, 2023

Most employer-funded benefit plans audit themselves annually, if not more often, given the value of a claim review. If you're in-house managing a plan and are thinking of scheduling a healthcare audit, do it sooner than later. One of the best times is shortly before you plan and budget for next year. In addition to flagging recoverable errors, an audit provides factual data to compare with the reports received from your outsourced claim administrator. When budgeting and forecasting for the coming year, having a clear handle on the most recent year is invaluable and improves your planning.


One of the best things about claim audits is your ability to add requests and questions to the review. Conscientious auditors carefully tailor their examination to the factors that matter most to you. Ideally, they work in the field continuously and bring their experience from prior audits. Their ability to focus on areas where mistakes have most likely occurred for other plans helps. It's also tremendously helpful to audit in the wake of extraordinary events like the coronavirus pandemic. They put plans under unique strains, and unwinding it afterward – and recovering overpayments – is crucial for many reasons.


Today's audits are known for checking 100 percent of claims. The vast majority of the work is handled electronically and quickly. Human oversight comes with system setup and final review of the reports generated. When the same auditors provide ongoing oversight, you can compare reports from each audit period for added insight. Confirming the self-reporting from your claim administrator with an independent review means everything. There's no doubt that today's error rates are in the low single digits, and accuracy is at an all-time high. But the expenses are big enough to warrant a close review.


The relentless drive to improve audit systems and software has ushered in a new era of claim reviews. Gone are the days when only large groups of repeating errors could be recovered. Today, when all claim payments are checked, it's possible to go after individual claim recoveries when the dollars are high enough. It also helps prevent future mistakes when past errors are caught and systems fixed. Over time, it leads to unprecedented accuracy and well-managed plans. Members also benefit from accurate and consistent claim payments. They mean everyone is treated fairly and equally.