Medical claim auditing is critical to overseeing large employers’ self-funded medical and prescription plans. Implementing new administrators (TPAs) for medical claims and pharmacy benefit managers (PBMs) for prescriptions requires careful auditing to ensure accuracy and efficiency. Therefore, getting an early start is crucial. For example, running a thorough audit 90 days after a new claim processor takes over is essential. At this stage, there is enough data to evaluate the accuracy of the new system, address potential issues, and prevent them from escalating into significant problems.
Confirming the accuracy of the setup and identifying overcharges and errors early on can save employers from costly mistakes. Following the implementation phase, continuous monitoring services can also help with near real-time oversight of claim payments. It helps ensure that plan sponsors are fully informed and that any issues are identified and addressed promptly. Ongoing monitoring provides a proactive approach to detecting cost trends early and taking corrective action before they become substantial financial burdens. It has proven itself valuable for health plans of all sizes and types.
Independent auditing firms specializing in claim processing are equipped to conduct comprehensive audits that overlook no detail. These audits ensure that TPAs and PBMs are meeting accuracy guarantees and that claims are being processed in accordance with plan documents. They meticulously review each claim for dozens of factors, producing audit reports covering even minute details of the processing setup. Thorough implementation audits are vital for ensuring claim processing accuracy, maintaining control over costs, and ensuring members receive services properly.
By partnering with independent specialist auditing firms, employers sponsoring benefits plans can comprehensively understand their claim processing while securing the best possible outcomes for their employees. Lately, class-action-minded law firms have been filing fiduciary breach lawsuits against large plan sponsors. This has been a wake-up call and caused everyone to adopt best practices for plan management. Audits are crucial in gathering needed data and independently verifying quality outcomes. Plan sponsors, in the habit of auditing their claims, have significantly less legal exposure.
