What secret weapon do medical claim auditors use to stay ahead of their competitors? Proprietary systems, software, and methods. Each firm has developed its protocols in response to client needs through the years. You want to review past clients and case studies before selecting an auditor. They aren't all alike. Highly effective claim reviews require audit skills and medical billing knowledge. One without the other won't get you as far, and you want the best oversight for your plan. It's routine today to review 100 percent of claims and check each in multiple ways.

The most significant improvements have come with the electronic review portion of an audit. Software advances have been the game changers, so the digital review portion of a claim audit now covers more. It means less human involvement, although auditors, with their trained and experienced eyes, still closely review the final reports. That's where you want someone with medical billing expertise involved. Most claim audit firms have senior executives with professional experience, including large health plans. They bring a unique understanding of medical billing, coding, and claim administration.

Another way to evaluate the effectiveness of claim auditors is to compare their reports and the value of the recoverable errors they flag. There are standard irregularities every good firm will find, but some have methods that discover more. Audit set up and ensuring their systems follow your plan's provisions closely is a crucial part of the process. When they take the setup seriously, it increases the chances of a highly effective audit. Firms competing for your business and wanting to demonstrate they can help your self-funded plan's bottom line the most will do their best – and you'll benefit from it.

Independence is a significant selling point in claim auditing, and when you find a firm with nothing but your plan's best interests in mind, it helps. Every audit should be custom-designed, and anything even remotely resembling a cook-cutter approach won't help. It's also helpful if your auditor has prior experience auditing a plan running on your outside processors' system. While all processors have some things in common, each has unique attributes. The value of an audit lies in the details, and you want to get them right for your plan. Customized claim auditing generally has a higher error detection rate.