Large corporate and nonprofit organizations that self-fund their health plans can unlock substantial advantages through claim auditing. For those using third-party administrators (TPAs) and pharmacy benefit managers (PBMs), scheduling TPA and PBM auditing services is beneficial. With most claim processing now outsourced, it is crucial to verify the accuracy of claim payments. An independent audit confirms that operations are running smoothly and identifies areas that may require attention. Despite the diligence of third-party administrators in processing claims, discrepancies are often inevitable.

Advancements in technology have transformed how businesses manage various functions, including medical and Rx claims. The billing process for both areas is intricate, involving variables and specific provisions. Considering the large amounts of money at stake, it's evident why routine auditing can reveal significant recoverable overpayments. The era of random sampling has given way to reviews of every claim, establishing this approach as the standard. Electronic audits now perform much of the workload, supported by cutting-edge systems and software that are continuously enhanced.

Pharmacy plans also present challenges related to formularies and the frequency of script dispensing. Modern systems are designed to promote the use of generics when available and align refill schedules with prescribed dosages. However, lapses can occur, and for large plans with thousands of members, even minor discrepancies can accumulate quickly. Auditors focusing on claim payments can identify patterns of frequently occurring transactions, which can highlight areas that require correction and improvement. Once repayment is requested, providers become more vigilant in their invoicing practices.

Ultimately, the objective of any benefit plan is to effectively serve its members while managing costs, particularly in a landscape marked by rising expenses. Having access to accurate data regarding claim payments is valuable, especially for those overseeing an external processor. Such factual insights support practical discussions in meetings and negotiations, facilitating needed changes without unnecessary pushback. Robust oversight is critical, especially during unprecedented events like the coronavirus pandemic, ensuring that control is maintained even in challenging circumstances.