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Historically, pharmacy and medical claim auditing focused on regulatory requirements. However, modern auditing is now recognized as a management tool in the healthcare industry. Advancements in methods and technology have improved the accuracy of audits, making them a valuable resource for plan sponsors. Better audits with enhanced accuracy, make routine auditing advantageous for plan sponsors. As a result, it's becoming increasingly common for plan sponsors to leverage audit software to continuously monitor their claims payments in the background, ensuring accuracy and compliance.
The increasing trend of outsourcing medical claims payment processing to third-party administrators (TPAs) and prescription claims to pharmacy benefits managers (PBMs) has increased the need for oversight. In the past, some plans handled claim payments in-house, giving them direct control over their operations. Therefore, the shift to TPAs and PBMs has rendered independent review essential for ensuring financial security and high-quality member service. Engaging a specialist auditor to review 100% of claim payments is the most accurate way to ensure that performance guarantees are met.
Both corporate and nonprofit employers sponsoring medical and pharmacy plans have recognized the many advantages of annual claim audits, especially from a financial standpoint. These audits not only contribute to the recovery of funds by identifying overpayments, duplicate charges, and other errors but also prove to be cost-effective, often recovering four times more than the cost of the audit. Continuous claims monitoring provides valuable cost trend information, enabling proactive decision-making and resource allocation. The independence of the chosen audit firm is crucial for achieving optimal results.
Furthermore, clear and actionable reports are essential for meaningful discussions with TPAs and PBMs regarding their performance and accuracy. In summary, the shift towards recognizing the value of audits in medical and pharmacy claims management as an essential management tool, coupled with the improvement in technology and methods, highlights the advantages of annual claim audits for both plan sponsors and members. By leveraging the expertise of independent auditors, plan sponsors can substantially improve the accuracy of claims processing, and ensure high-quality member service.
The increasing trend of outsourcing medical claims payment processing to third-party administrators (TPAs) and prescription claims to pharmacy benefits managers (PBMs) has increased the need for oversight. In the past, some plans handled claim payments in-house, giving them direct control over their operations. Therefore, the shift to TPAs and PBMs has rendered independent review essential for ensuring financial security and high-quality member service. Engaging a specialist auditor to review 100% of claim payments is the most accurate way to ensure that performance guarantees are met.
Both corporate and nonprofit employers sponsoring medical and pharmacy plans have recognized the many advantages of annual claim audits, especially from a financial standpoint. These audits not only contribute to the recovery of funds by identifying overpayments, duplicate charges, and other errors but also prove to be cost-effective, often recovering four times more than the cost of the audit. Continuous claims monitoring provides valuable cost trend information, enabling proactive decision-making and resource allocation. The independence of the chosen audit firm is crucial for achieving optimal results.
Furthermore, clear and actionable reports are essential for meaningful discussions with TPAs and PBMs regarding their performance and accuracy. In summary, the shift towards recognizing the value of audits in medical and pharmacy claims management as an essential management tool, coupled with the improvement in technology and methods, highlights the advantages of annual claim audits for both plan sponsors and members. By leveraging the expertise of independent auditors, plan sponsors can substantially improve the accuracy of claims processing, and ensure high-quality member service.