Good reasons to audit group data

Audits of employer groups' medical and pharmacy claims should occur every one to two years, with extra "implementation" reviews done when new claims-related vendors start working, according to Employee Benefit News. "Every plan will have claims paid in error," the article noted. "[T]here will always be instances of duplicate billing, wrong or missing accounts and rebates, mistakes in member eligibility, incorrect plan setup or other problems." Medical claims audits should examine outlier physician charges and coding discrepancies, including procedure codes billed together that are mutually exclusive. Pharmacy audits should check compliance with formulary requirements, patterns of early refills, quantity limits and application of clinical edits. These audits are often fruitful, routinely flagging errors representing 3 percent to 5 percent of overall claims expense, EBN noted. Article

 

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