In the past, self-funded corporate health plans were audited using periodic random-sample methods. While this approach satisfied regulatory requirements and was standard practice, it had major limitations. In the 1990s, however, a notable change occurred as innovative companies began leveraging software developments to review 100 percent of claims for medical and PBM audits. This extensive...
For years, large employer-sponsored health plans have relied on medical claim audits to assess their own performance and that of their third-party administrators. While payers typically receive the most attention for claim reviews, healthcare providers also stand to gain significant benefits from audits medical claim auditing Although some providers attempt to handle audits...
Corporate employee benefits executives manage some of the most significant expenses within their organizations. As medical and prescription costs continue to increase, medical claim and pharmacy benefit manager audits play a vital role in verifying that company funds are being used appropriately. The type of audit employed is important. Traditionally, benefit claims were audited using a random...
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