When large employers that self-fund their health plans switch to new third-party administrators or pharmacy benefit managers, the expectations are high. But only medical claims auditing that also covers pharmacy plans can confirm the promised improvements are happening. Onboarding a plan and all of its details onto a claim processing system is a feat, and no matter how experienced TPAs or PBMs are, they can make errors and omissions. It's why a scrupulous audit at the 90-day point is so crucial. It provides processing and payment accuracy and consistency data – it's the ideal plan management tool.
If you work for a plan sponsor and have management responsibilities, make sure you look for independent auditing firms with expertise. Their only objective is your plan's best interests. Also, make sure you have one with advanced electronic review capabilities that cover 100-percent of your claims. Random sample audits that are less accurate quickly become a thing of the past, and high-performing plans select a 100-percent review. There is no substitute for having accurate reports in your hand when you're working with TPA and PBM representatives. You'll find and solve problems efficiently.
The tough news for medical and pharmacy plans is the never-ending increase in costs for services and medicines. But better auditing does help make sure negotiated rates and discounts are applied as promised. It's why close oversight has become steadily more important. When relying on third parties to handle significant cash outflows, it's imperative to double-check their accuracy. Audited plans also perform better over the long haul as errors are detected and systems corrected to prevent the same ones from recurring in the future. Easier-to-read audit reports also are the new normal.
Once they see the value of 100-percent auditing, many health and pharmacy plan sponsors have requested the same software to run in the background continuously. Known as a continuous monitoring service, the cost-saving results it produces are impressive. The errors detected and overcharges recovered far exceed the cost of the service. It's also a way to stay on track with budgets and understand emerging trends driving costs (or cost increases). Knowledge and information are power, and auditing gives them to health and pharmacy plans. Claim payment accuracy is a must for many crucial reasons.
