The implementation of a medical claim and Rx audit process presents multiple opportunities, particularly after transitioning to a new processor. Shifting claim administration to a new processor holds potential benefits, but it is crucial to assess whether these are being realized. A comprehensive review is necessary to provide an accurate answer. With the increasing complexity of medical costs and services, ensuring proper claims payment has become more challenging.
Although large health plans acting as third-party administrators for self-funded plans possess considerable expertise, they are not immune to errors. Scheduling an implementation audit 90 days after a new processor begins work is ideal, as this timing allows for a substantial number of claims to be processed on the new system, making it sensible to double-check their accuracy. Detecting errors early on can prevent them from snowballing into larger problems, and an audit may also reveal anomalies that were previously undetected. Independent specialist claim auditors bring valuable experience and systems to the table, enabling them to detect even minor issues.
While various audit firms exist, many professionals in the benefits administration field believe that smaller independent firms are preferable. These firms often exclusively audit claims and employ staff with experience at large health and pharmacy benefit plans, positioning them uniquely to develop accurate systems and methods due to their deep understanding of the industry. Their independence allows them to prioritize their clients’ interests without conflicting allegiances. On the other hand, larger firms may have relationships on both sides of the equation.
An effective implementation audit sets the stage for a smooth transition and promises enhanced efficiency and cost savings. Independent oversight is crucial to verifying that assurances regarding accurate claim processing are met and can support fiduciary responsibilities for for-profit corporations with self-funded health plans. Significant increases in claim costs can impact quarterly earnings reports and the bottom line, making it essential to control costs and provide explanations for budget overages or unexpected events. An implementation audit can address all these concerns.