Today, 04:28 AM
Large employers—both corporate and nonprofit—that sponsor benefits plans have a vested interest in ensuring claims are managed accurately. Today, medical claim and PBM audits are more essential than ever. One of the most critical times to audit is following a transition to a new TPA (third-party administrator) or PBM (pharmacy benefits manager). Even with thorough initial setup, new vendors often have system issues that need correction once operations begin. Spotting even minor mistakes prevents them from worsening. Scheduled audits save money and lighten administrative duties.
While most TPA and PBM contracts include performance guarantees, only independent, comprehensive audits can confirm those standards are met. Implementation audits frequently reveal issues that vendors miss in their own systems—especially with more complex plans, where the room for error increases. Auditing enhances member service and secures consistent claims processing for all participants. It not only identifies isolated mistakes but also reveals trends that may impact multiple claims. As an in-house plan manager, you benefit from actionable, analytics-based insights.
Today’s advanced audits review 100% of all claims paid, a major leap forward from the old random-sample methods—with no increase in cost, thanks to sophisticated software. Specialist audit firms consistently refine their technology, reaching new levels of accuracy in electronic reviews. Unlike random sampling, a full audit can find and fix every payment error. After your initial implementation audit, annual claims reviews are recommended, and many organizations now opt for monitoring services that offer real-time reporting. They customarily produce detailed monthly reports.
If you’re weighing the value of comprehensive, 100% claim auditing, consider that it often recovers up to four times its cost. For this reason, plan sponsors increasingly view auditing as an important management and oversight tool—and as a way to fulfill fiduciary duties. Auditors continue to improve their technology and processes, delivering results far beyond what was possible just a decade ago. As medical and prescription expenses keep rising, frequent audits are more important than ever. Start with an implementation audit and maintain annual reviews going forward.
While most TPA and PBM contracts include performance guarantees, only independent, comprehensive audits can confirm those standards are met. Implementation audits frequently reveal issues that vendors miss in their own systems—especially with more complex plans, where the room for error increases. Auditing enhances member service and secures consistent claims processing for all participants. It not only identifies isolated mistakes but also reveals trends that may impact multiple claims. As an in-house plan manager, you benefit from actionable, analytics-based insights.
Today’s advanced audits review 100% of all claims paid, a major leap forward from the old random-sample methods—with no increase in cost, thanks to sophisticated software. Specialist audit firms consistently refine their technology, reaching new levels of accuracy in electronic reviews. Unlike random sampling, a full audit can find and fix every payment error. After your initial implementation audit, annual claims reviews are recommended, and many organizations now opt for monitoring services that offer real-time reporting. They customarily produce detailed monthly reports.
If you’re weighing the value of comprehensive, 100% claim auditing, consider that it often recovers up to four times its cost. For this reason, plan sponsors increasingly view auditing as an important management and oversight tool—and as a way to fulfill fiduciary duties. Auditors continue to improve their technology and processes, delivering results far beyond what was possible just a decade ago. As medical and prescription expenses keep rising, frequent audits are more important than ever. Start with an implementation audit and maintain annual reviews going forward.