Medical claim and PBM audits that review all payments using advanced proprietary technology frequently discover important findings, which is why they are so valuable. While most claims are paid accurately, the real value comes from identifying errors and discrepancies. These audits can yield a remarkable return on investment, recovering overpayments that can be as much as four times the audit cost. They also strengthen claims administration for self-funded plans, which third-party administrators often manage. Technological advancements in auditing software continue to improve accuracy.

Auditing medical claims and pharmacy benefit managers (PBMs) opens the door to both financial recoveries and systemic improvements. A key step is benchmarking your administrator’s performance against industry standards and best practices. Next is spotting errors and identifying trends that can be corrected through systemic changes. Once errors are flagged, you can pursue recoveries for overpayments and other mistakes. Oversight also enables plan sponsors to collaborate with TPAs for future improvements and ensures compliance with federal and fiduciary regulations.

Independent claims auditors offer the greatest value because they remain unbiased and dedicated to this specialty. Their ongoing development of systems and processes ensures top performance. A primary benefit of these audits is verifying the performance guarantees set in claim administration contracts. If a TPA underperforms relative to industry benchmarks, targeted improvements can be made to align claim payments with expectations. Comprehensive electronic reviews of all claims consistently exceed random sampling and guarantee fair treatment for every member as they boost accuracy and consistency.

Large employers who sponsor benefit plans typically audit pharmacy benefit payments just as thoroughly as medical claims. Prescription plan audits create opportunities to review pricing, discount guarantees, rebates, and to detect fraud, waste, and abuse. These examinations may also produce recommendations for adjusting formularies to capitalize on evolving market opportunities. Because the landscape changes annually, it is essential to stay informed. Auditors with daily field experience can provide valuable insight into how other plans are achieving better results.