Claim Audits for Employer-Funded Plans

<?xml encoding="utf-8" ?>Both corporate and nonprofit health plan sponsors, particularly those that self-fund their plans, stand to benefit from meticulous medical claim and <a href="https://www.tfgpartners.com/prescription-claims-auditing/" target="_blank" rel=" noopener">PBM auditing services</a>. These audits are crucial for overseeing third-party administrators and pharmacy benefit managers responsible for managing claims and payments. When health carriers bring their provider networks and negotiate rates, outsourcing claims processing often proves to be a smart financial strategy. However, the key to realizing cost savings lies in the accuracy of claims processing—and that's where independent reviews come into play. Even plans that utilize self-auditing third-party administrators (TPAs and PBMs) should periodically engage an unbiased external auditor to ensure everything is on track. The claim audit field has evolved remarkably over the years, thanks in part to technological advancements. This shift has improved efficiency and resulted in financial recoveries that can be up to four times the cost of the audit itself. Many plan sponsors have realized the importance of routine audits, shifting from conducting them only as mandated by law to integrating regular audits as part of their management practices. When it comes to auditing claims, employer-sponsored benefit plans can reap rewards, but health and pharmacy plans present the most significant financial opportunities. With their complex treatments and higher costs, the potential for errors and oversights increases, even when TPAs perform well. This reality underscores the value of effective auditing. The emergence of specialized firms focusing on claims audits reflects this need, bringing significant expertise in medical and pharmacy benefits. These independent firms prioritize the sponsor and its members' interests without conflicting loyalties. Also, implementation auditing should be a serious consideration for sponsors transitioning to new TPA claim processors or pharmacy benefit managers. A thorough 100% audit around the 90-day mark can reveal any irregularities, which are often the root of systemic errors impacting multiple claims. Continuous monitoring services are also becoming popular, allowing sponsors to track claim payments in real-time, helping to spot the mistakes before they lead to significant financial losses. Consistent auditing practices enhance the reliability of claim processing and boost the effectiveness of health plans.