Large employer-sponsored health plans for years have used medical claim audits to evaluate their plan's performance and that of their third-party administrators. Therefore, payers receive the most attention for their claim audits, but providers can also benefit. Some try to handle it in-house, but an increasing number are working with claim auditors to review their billing. Errors in coding or other mistakes in the patient's favor can cost medical facilities and practices thousands. Given the potential exposure, the cost of an auditor's services may be revenue positive in nearly every case.

In an environment where expenses run high and price increases are standard, making sure billing is correct and patients are charged for all services rendered is essential. Few people set out to make mistakes, but staff may not focus on billing in the rush of the moment or at the end of a long day (or shift). Oversight and review in the form of an audit can be enlightening and might be the starting point for meetings or training sessions. Everyone understands their salaries flow from revenue, and when there are undercharges, it hurts everyone. Focusing more attention on correct coding is beneficial.

Auditors can produce a clear picture of past billing when using the most advanced software that reviews 100 percent of claims. The electronic review detects virtually everything, and human oversight and re-running some aspects improve the quality even more. It's a far cry from the random samples of the past that gave some indication of results but easily could have missed things through no one's fault. The staff time saved by more sophisticated electronic capabilities is also meaningful. It's less demanding to run an audit when auditors and their software can bring it to completion with less client involvement.

The continuous monitoring service increasingly favored by payers to keep tabs on claim payments might go farther than providers need, but it's worth considering. If you've had billing and revenue shortfall issues, auditing claims filed for a year or other period until things are running correctly could be a wise idea. Nothing beats careful oversight as a management tool, and it's a way to stay focused on a problem until it is resolved. It's clear that the same claim audits that began as a regulatory and compliance necessity for some have taken on new importance. They are a tremendous tool for payers and providers.