At first, a healthcare audit might sound complicated and it's accurate many details are involved. But if you are responsible for managing a self-funded plan and need to conduct claim processing oversight, few things are as helpful. The objective is to confirm claims are being paid correctly and mistakes are avoided, but getting to those findings takes detailed work. Each claim has hundreds of data points to check, and a sophisticated electronic review is the first step. Auditors then review the results and either draw conclusions or re-run part of the batch – their experience guides the process.

Continuous improvements in technology make a claim audit more effective. Today's systems run faster and pick up finer details than ever before. It's why auditors today can routinely flag recoverable mistakes that are worth several times the audit's cost. The budget friendliness leads plan sponsors to audit more often, which keeps their plans running more cost-effectively. Members expect and deserve to be treated equally, which only happens when claims are paid accurately and consistently. Otherwise, some may receive preferential treatment by coincidence, which goes against plan guidelines.

For many years, claim auditing was thought to benefit payers, and providers may have had less interest in it (or urgency about it). But as methods have improved and coding has become more complex, there has been an increasing tendency to audit by providers. A significant consideration is checking to see that revenue is correctly captured for services rendered. It also goes to staff training and management. If you find billing and coding errors that are causing your facility or practice missed revenue, it's a serious consideration. Oversight and follow-up have become vital management tools.

Back on the payer side, many today monitor their claim payments continuously. It's the best way to keep tabs on plan performance and make adjustments as soon as needed. If errors occur, they're caught early, requesting reimbursement and correction earlier. Working months or years in arrears is less clear-cut, and there is much more opportunity for complex negotiations. It's hard to imagine any upper manager who would not appreciate clear and immediate answers about claim costs. Well-run plans benefit their sponsors and members equally and better meet both needs.