Picture a night watchman on a street of a thousand houses. He carries one torch. He is diligent, unbribable and genuinely committed to his work. Every night he walks the lane, chooses three houses at random, checks their locks, and files a report at dawn confirming that three houses were secure.

He is not lazy. He is not corrupt. He is simply outnumbered by arithmetic, and arithmetic has never cared about anyone’s character. That watchman is the modern healthcare audit function, and the street gets longer every year.

Traditional audit rests on one quiet assumption: you cannot look at everything, so you look at a slice and reason outward. That was perfectly reasonable when claims moved on paper, and a hospital’s billing department could be walked end to end in an afternoon. That world has left the building. A mid-sized insurer today processes claims in volumes no sampling frame can honestly represent. Pulling a few hundred files out of several million is not oversight. It is theatre with good production values. It leaves the overwhelming majority of transactions untouched by any judgment at all.

Worse, that slice is drawn after the money has already moved. Retrospective review is post-mortem work. It can tell you with beautiful precision exactly what went wrong. It cannot undo it. The industry even has a phrase for the arrangement – pay and chase. Pay first, ask questions later. Strip away the professional gloss, and it stops sounding like a strategy and starts sounding like a confession.

Our systems still pay first and ask questions later. The world has moved on.

Our systems still pay first and ask questions later. The world has moved on.

To be fair, insurers do run automated checks at the front door. If a code sits beside an incompatible diagnosis, flag it. If frequency crosses a threshold, hold it. Rules work. Rules also advertise themselves. Every denial is a free tutorial, and those inclined to game a system are attentive students. A pattern blocked on Monday is reshaped by Wednesday – the code nudged one digit........

© Daily Times