Each Year Brings Reasons to Audit Benefit Claims

The COVID-19 pandemic profoundly affected medical and pharmacy benefit plans, especially those of large employers who self-fund their plans. In response to these challenges, a healthcare audit to doublecheck medical and pharmacy benefit plans is needed. Plan sponsors are increasingly turning to audit firms to identify overcharges, payment errors, dispensing mistakes, and other anomalies that have emerged in the aftermath of the pandemic. The most effective and sought-after auditing firms are at the forefront of technological advancements and can conduct a comprehensive review of 100% of claims. 

These independent specialist firms, equipped with advanced electronic systems and human expertise, have become invaluable in ensuring thorough oversight of all paid claims. Given that no two plans are identical, identifying and addressing claim payment error patterns requires extensive industry knowledge and constant vigilance to stay ahead of emerging trends. When selecting an auditing firm, the value of independence cannot be overstated. Free from conflicting interests, specialist firms can provide the most candid and impartial assessments of plan performance and processing accuracy. 

In contrast generalist audit firms may have less expertise, making independent specialist firms the preferred choice for conducting audits. Moreover, the proprietary audit software employed by these firms is essential in ensuring accuracy in identifying payment discrepancies. Furthermore, to fully maximize the benefits of the audit process, it is crucial to prioritize 100% reviews rather than relying on random samples. Clear audit reports are also essential in providing concrete data for productive discussions with third-party administrators for medical plans and pharmacy benefit managers. 

The findings from these audits pave the way for system improvements. Additionally, leading auditing firms demonstrate their commitment by actively engaging in meetings to explain the identified opportunities for system fixes and upgrades. These proposed improvements can lead to consistent and noticeable cost savings, making them a critical outcome of the audit process. By continually evolving and adapting to the changing landscape of medical and pharmacy benefit plans, superior auditing firms play a pivotal role in driving sustainable improvements and cost efficiencies to benefit their clients.