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Employers who provide benefit plans are intensely interested in conducting annual claim audits to identify errors, recover data, and highlight systemic issues. Regular medical claim auditing ensures that third-party claim administrators and pharmacy benefit managers maintain accurate records. Audit reports are valuable tools for managing one of the most significant expenses for any company - the same holds true for large nonprofit employers with self-funded medical and pharmacy plans. Doublechecking claim payments matters in an era of inflation and never-ending medical cost increases.
Effective oversight is always crucial for the complex process of claim processing. When selecting and scheduling a claim audit firm, it's important to inquire about their process. Look for a firm that reviews 100% of claims, as the traditional random-sample method has proven less accurate. With today's advanced software, checking every claim when you engage the right firm is just as efficient. This approach provides actionable reports that form the basis for discussions with your TPA and PBM regarding ongoing errors and system improvements, improving accuracy and helping manage costs.
If your vendors resist the idea of an audit, it could be a red flag. Reputable firms typically welcome an independent confirmation of their accuracy and good work. Conversely, a claim administrator pushing back on an audit may be aware of significant error patterns or overpayments. Well-managed plans also benefit members by ensuring accurate processing, which is especially advantageous for those with high deductible coverage. Because their out-of-pockets are affected by accurate claim processing, high-deductible members depend on accuracy in claim payments.
Audits are essential for fulfilling fiduciary responsibilities. Interest in claim auditing as a management tool, rather than just a regulatory compliance issue, has surged during the coronavirus pandemic. Plans faced unprecedented overcharges and increased utilization rates, making auditing essential to examine claim experience closely. TPAs and PBMs also experienced staffing challenges during this period, further emphasizing the need for closer plan management and review of claim payments. Don't delay scheduling your annual audit to run timely oversight, especially in light of medical and Rx cost increases.