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When it comes to health and Rx plan claim payment oversight, many plan sponsors focus on one primary benefit: recovering overpayments. While this is a significant advantage, the actual, long-term value of medical plan and pharmacy benefit manager audits lies in identifying systemic errors. These mistakes often lead to inaccuracies that accumulate over time, resulting in higher costs and demanding correction efforts. In essence, claim audits not only have short-term benefits but also play a vital role in cost containment, customer service, and ensuring equitable treatment for all members and their claims.

Addressing setup issues proactively can lead to lasting improvements. Whenever your plan transitions to a new third-party administrator (TPA) for medical claims or a pharmacy benefit manager (PBM) for prescriptions, consider conducting an implementation audit about 90 days after the switch. This step is crucial to confirm your plan's configuration is accurately reflected in the new system and that claims are processed with the precision you expect. If your contract includes performance guarantees, an independent audit can assure that those standards are being met.

Reputable TPAs and PBMs are typically open to audits as a testament to their quality of service, while those that seem hesitant might warrant further scrutiny. It's important to note that while most TPAs and PBMs manage multiple plans with standardized setups, your particular plan may possess unique elements that can complicate matters. It makes the implementation audit even more essential. By investing in this early review, you can ensure a smoother transition to the new vendor and help keep everything on track. Ideally, things go smoothly, but if not, it's vital to catch and correct issues quickly.

Also, it's wise to perform regular audits since high-quality claim auditing can often uncover savings that are up to four times the cost of the service —an eye-opening realization for many plan managers. Also, if your usual practice has been to conduct random sample audits, you might want to reconsider. Look for an auditing firm that commits to reviewing 100 percent of your claim payments. This comprehensive approach can provide a more precise and more accurate understanding of your claims process and financial position, ultimately leading to better decision-making and management of your health plan