Given the substantial amounts involved, healthcare audit services are a critical safeguard for employer-funded health and pharmacy plans. Regularly verifying medical and prescription claim payments is not only a good management practice, but it also plays a significant role in controlling costs. Third-party administrators (TPAs) and pharmacy benefit managers (PBMs) are entrusted with disbursing your company's funds. While most of them take this responsibility seriously and maintain low error rates, the complexity of service agreements indicates a meticulous review to ensure compliance with the terms.
Engaging auditors can provide the crucial validation you need in the long run. Even with careful self-regulation, it's likely that some discrepancies will slip past claim processorsdiscrepancies that auditors would catch. Reputable auditing firms have experience across a variety of plans and understand the key areas to scrutinize. Their expertise also comes from a detailed understanding of your specific plan provisions, which allows them to tailor their claim payment reviews. It's striking how often an auditor's recommendations can lead to systematic improvements that yield benefits for years to come.
Adopting an analytical approach to the payment process, along with an examination of the criteria used in the claims processor's system, is essential, particularly since many processors are large health carriers operating with their provider networks and methods, sometimes running on autopilot. The timing of audits can further enhance their effectiveness. For instance, scheduling an audit just before the annual budgeting process can be advantageous. Similarly, conducting one three months after transitioning to a new processor for claim payments can reveal system adaptations.
Recent advancements in auditing technology enable comprehensive reviews of all claims rather than relying on random samples. It has significantly increased accuracy, enabling diligent monitoring of each payment against numerous data points, making irregularities evident at both the group and individual claim levels. The landscape has transformed for plan managers overseeing claim administrators. Queries for auditors can now be addressed in subsequent audits, and the most proactive plans utilize continuous audit software, often recouping far more than the cost of such ongoing oversight.
