Healthcare costs are a constant reality; the trend shows they increase yearly. Even during periods of low inflation, these costs continue to rise, putting financial pressure on everyone involved, including large employers who self-fund their healthcare plans. Therefore, utilizing a medical claim auditing service to review payments becomes essential, especially during rapid inflation. No matter how many accuracy guarantees third-party claim processors offer, the only way to ensure the correctness of recent charges is through thorough checks. Independent oversight is the best answer.

For plan sponsors, maintaining oversight is more critical now than ever as expenses escalate. In addition to assessing claim payments, an audit can also explore the rationale behind certain charges, which can uncover new cost-containment opportunities. For instance, unnecessary duplicate tests and services lead to overutilization that provides no benefit to members. Such wasteful practices contribute to rising costs that put a strain on budgets. When audits identify these issues and initiate discussions with providers and claims processors, plans can seize savings opportunities that accumulate over time.

Providers tend to be more cautious when they know they're being monitored. Technological advancements have enhanced audit capabilities without raising service costs. As systems have been refined to capture necessary details, conducting oversight has become more manageable. In the past, audits relied on random samples and significant human oversight. Today, electronic claim reviews can evaluate 100% of claims with less need for human intervention. The most effective auditors are specialists who have developed proprietary systems to audit any third-party claim processor.

Looking ahead to the new year, changes in federal legislation affecting Medicare will lead to shifts in costs for certain pharmaceuticals. As Medicare negotiates lower prices, drug manufacturers may seek to recover lost revenue through other means. Even if your pharmacy benefit manager (PBM) is vigilant, an auditing process is wise. When significant payers adjust their rates, it inevitably creates market turbulence. Historical experience shows that pharmaceutical companies often find ways to increase their revenue. Strengthening your plan with safeguards is a prudent strategy.