Large employer-sponsored health plans have increasingly outsourced their claim administration to achieve greater efficiencies and economies of scale. By partnering with major carriers, these plans provide members access to expanded provider networks and comprehensive services. However, oversight continues to be important to ensure that claims are handled properly and contractual obligations are met. This is where medical and PBM auditing services play a vital role. Applying advanced auditing software, these reviews deliver highly accurate results via systematic analysis of all claims.

Many employer-sponsored health plans work with third-party administrators (TPAs) and pharmacy benefit managers (PBMs) to process claims. Audits are necessary for verifying that the agreements are being fulfilled and that claims are handled correctly. Even small error rates can result in considerable financial losses due to the high costs of medical care and prescriptions. Conducting routine audits not only identifies errors that might be missed by internal controls, but also assists in maintaining oversight and control over externally processed claims, protecting the plan’s financial well-being.

The most effective healthcare plan auditors have paired expertise in auditing and claim processing. Many started their careers with large health plans and have transitioned to auditing. It gives them specialized knowledge that saves time and increases accuracy. Medical and pharmacy claims can be complex, and each plan covers specific services and medicines. When a large health insurance carrier takes on processing, they add the plan to its system. Some items may revert to their system defaults and don't honor a plan's particular details. Auditors can detect and flag irregularities for review.

In addition to standard audits, implementation audits are highly beneficial. The initial transition period with a new administrator often leads to errors, and audits can detect and correct these issues. Ongoing monitoring makes certain that your plan benefits from expert oversight year-round. Real-time detection and recovery of overpayments is far more effective than attempting to resolve issues months later. Continuous monitoring also helps catch systemic errors and prevent them from growing into major losses. Also, it plays a key role when identifying potential patterns of fraud or abuse.