Large employers care for their employee's health care needs with self-funded plans for sound financial reasons. But those plans need medical claim auditsmples that were less accurate, they were used for regulatory compliance. But today, they are a valued management tool, and auditors check 100-percent of claims paid down to an impressive level of detail. It means far fewer errors go undetected, and more frequent audits and monitoring aid the recovery of funds. When overcharges are caught sooner, they are easier to recover.
Improvements in technology have ushered in the new era of claim auditing, and plans are the ultimate beneficiaries. The trend for more frequent audits also has been encouraged by increased outsourcing of claim payments and administration. Third-party administrators handle things today, and plans need oversight of their work. It's the same for prescription claims, with pharmacy benefit managers running the payments and processing. When plans cover services and medications for their employee-members, they need to be paid consistently in fairness to all. It's why audits also improve member services.
A group of independent claim auditing firms has arisen with unique expertise in the field. They far out-do generalist firms with competitive pricing and accuracy. It's because their people work in the field every day and stay abreast of trends and developments. While generalists may understand the fundamentals of auditing, they may not work on pharmacy and medical claims every day, and they can't be as well versed. When you're interviewing firms to audit your medical plan, keep an ear out for those who specialize in the field. You want their expertise to help your company plans.
When you start with a new PBM or TPA, remember to schedule a 90-day implementation audit to double-check how well they've set you up in their system. Too many plan sponsors have learned the hard way about missed parts of performance guarantees. Ultimately you will catch them in audits later, but if you check shortly after implementation, you can avoid million-dollar error patterns that are time-consuming to correct. Medical and pharmacy claim costs substantially impact the bottom line, as everyone saw again during the coronavirus pandemic. Audit your plan and keep it running right.
