Ensuring high-quality healthcare at reasonable costs involves various factors, leading many large employers to sponsor health plans for their employees. One area often deserving more notice is pharmacy and medical claim audits, which are crucial for oversight and quality review. With most claim payments now handled by third-party administrators and pharmacy benefit managers, are essential management tools for plan sponsors. Many employers now conduct frequent audits or have their claim payments continuously reviewed by auditing firms, aiming to improve quality and control costs.

Today, in-house benefits managers appreciate how auditors require minimal time during planning, set-up, and implementation. Specialized firms focusing solely on claim audits bring well-developed expertise, leading to improved accuracy, reduced costs, and a decreased time commitment from signing the agreement to obtaining final reports. Working with an independent auditor signals to third-party administrators and pharmacy benefit managers that the plan is actively managed to the highest standards, prompting them to keep a closer watch over their operations and methods.

Implementation auditing is also crucial. When beginning with a new third-party administrator or pharmacy benefit manager, conducting a thorough review after 90 days is essential. Every plan is unique and requires a customized set-up of the processor's system, and any oversights are best caught before they escalate into significant issues. While TPAs and PBMs often self-police against major problems, independent oversight provides a level of detail that is irreplaceable. Ensuring a plan is correctly set up on a processor's system results in accurate claim payments every time and ends repeating mistakes.

While many people associate claim audits with financial matters, it encompasses more than that. Audits also have a substantial member service dimension, improving efficiency and accuracy and ensuring equal treatment for all members. Processing and payment errors can favor some members over others, and accurate claim processing can positively impact members with high-deductible coverage. Ultimately, member services and conscientious cost management must apply the same standards for payment to all members. It helps plan sponsors meet their established fiduciary responsibilities.