Maximizing the value of medical claim and PBM audits for your benefits plans requires leveraging every aspect of the auditor’s report. Today, understanding audit findings is more straightforward than ever. Recent innovations have greatly improved two key aspects of medical and pharmacy claim reviews: clearer, more accessible reports, and the ability to review 100 percent of claims, rather than relying on random samples. Evaluating your self-funded plan's performance ultimately comes down to claim payments and their accuracy. When claims are paid correctly, you gain greater control over costs.
Seasoned benefits plan managers have observed transformative improvements in auditing over the years. Enhanced software and systems now make it easier to conduct audits and produce clear reports that highlight actionable opportunities. The most effective auditors partner with you after their review, helping implement systemic corrections that prevent recurring errors and uncover additional ways to improve. With hundreds of variables in medical and pharmacy claims, mistakes can happen at any stage. Even the most competent third-party administrators are not immune to occasional errors.
Ongoing monitoring, utilizing the same high-tech software and systems as audits, has grown increasingly popular. Large employers that self-fund plans can benefit from this improved oversight. Ongoing monitoring of third-party administrators offers many advantages, including demonstrating active management to stakeholders. In corporate environments, where C-suite executives are accountable for quarterly results, the ability to prevent or explain unexpected claim costs through monitoring is highly valuable. Clearly, health plan performance can markedly influence the organization’s financial condition.
Implementation auditing remains an essential element for catching errors before they magnify. As the saying goes, an ounce of prevention is worth a pound of cure—this is especially true in claim reviews, where early detection may prevent costly mistakes. Starting accurately enhances claim processing. While most third-party administrators are established health plans with effective systems, it’s important to ensure the specific rules of your plan are accurately applied. A thorough, 100-percent claim review is the most reliable way to verify that those adjustments are being made and maintained over time.
Seasoned benefits plan managers have observed transformative improvements in auditing over the years. Enhanced software and systems now make it easier to conduct audits and produce clear reports that highlight actionable opportunities. The most effective auditors partner with you after their review, helping implement systemic corrections that prevent recurring errors and uncover additional ways to improve. With hundreds of variables in medical and pharmacy claims, mistakes can happen at any stage. Even the most competent third-party administrators are not immune to occasional errors.
Ongoing monitoring, utilizing the same high-tech software and systems as audits, has grown increasingly popular. Large employers that self-fund plans can benefit from this improved oversight. Ongoing monitoring of third-party administrators offers many advantages, including demonstrating active management to stakeholders. In corporate environments, where C-suite executives are accountable for quarterly results, the ability to prevent or explain unexpected claim costs through monitoring is highly valuable. Clearly, health plan performance can markedly influence the organization’s financial condition.
Implementation auditing remains an essential element for catching errors before they magnify. As the saying goes, an ounce of prevention is worth a pound of cure—this is especially true in claim reviews, where early detection may prevent costly mistakes. Starting accurately enhances claim processing. While most third-party administrators are established health plans with effective systems, it’s important to ensure the specific rules of your plan are accurately applied. A thorough, 100-percent claim review is the most reliable way to verify that those adjustments are being made and maintained over time.