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When beginning a relationship with a new third-party administrator or pharmacy benefit manager, benefit plan sponsors are filled with anticipation. They look forward to accurately paying claims and managing the process cost-effectively. However, it’s essential to ensure that all the promises made by the new partner are being kept. The only way to confirm this is through medical claim auditing. Self-funded medical and pharmacy plans are known for their complexity, and integrating them into a TPA or PBM system can be challenging. Therefore, it’s essential to conduct a timely implementation audit.
Making a case for an implementation audit is simple because it’s the best way to verify claim payment accuracy. High-performing plans prioritize precise claims payment to serve their members best and stay on track with budgets. Both corporate and nonprofit employers face significant cost exposures with self-funded plans, making auditing a wise choice for effective plan management. When hiring an auditor, it’s advisable to find one that reviews 100 percent of claims, as it’s the most accurate method and produces the best results. It’s essential to be cautious if anyone suggests a random sample audit.
Most claim audit specialists recommend a check 90 days after implementation, which is the ideal point. There is enough payment experience to gain a good overview of accuracy, and it’s early enough to catch recurring errors before they become significant problems. Although more extensive plans with a high daily claim volume are prone to higher issues, plans of any size can be significantly affected. The typical problems revolve around setting up and ensuring the plan’s details are correctly entered into processing systems. Even diligent TPAs and PBMs make errors that warrant auditing 100 percent of claims paid.
Upon completing the implementation audit, keeping the audit software running in the background may be beneficial for continuous monitoring. It not only helps in saving money for the plan but also ensures that future errors are minimized. Constant monitoring can also alert you to utilization and price trends as they emerge, thus putting you in a better position to manage them effectively. While outsourcing claims processing can lead to cost savings, these benefits are only realized when handled accurately. Therefore, it’s crucial to consider scheduling thorough implementation auditing at the optimal time.
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