When health plan sponsors initially outsourced their claim processing to third-party administrators (TPAs), oversight wasn't a top priority. However, the increasing accuracy of healthcare audit services has highlighted their value as management tools. While self-reporting by TPAs and pharmacy benefit managers is acceptable, it shouldn't be the sole method of monitoring plan performance. Independent auditing firms are uniquely suited to provide oversight. They also bring insight into your plan’s performance based on their daily work auditing other plans -- there is no substitute for experience.
Two significant advancements in medical and pharmacy claim auditing have been the shift to reviewing 100% of claims and improving reporting methods. Today’s concise, easy-to-read statements have empowered sponsors to engage in meaningful discussions about performance and accuracy with TPAs and PBMs. Many sponsors have embraced continuous monitoring that allows real-time review of processing and payments, ushering in a new era of accuracy and accountability. When there are recoverable mistakes or overpayments, it’s help to flag and request reimbursement promotly.
Continuous monitoring services offer the crucial benefit of spotting significant expense trends early, allowing sponsors to plan and budget for new costs and manage them more effectively. Real-time monitoring is particularly valuable in managing unexpected events, such as utilization spikes and new costs, like those seen during the coronavirus pandemic. This insight is essential given the impact of claim expenses on the budget. Also, if there are expense fluctuations during a plan year, audit data can help explain them and track the trends. It’s always helpful to be on top of issues in their early stages.
The value of independent audit firms specializing in health plan and pharmacy claim reviews cannot be overstated. These firms, often led by executives with backgrounds at large health insurance carriers, bring invaluable insight and expertise. Their ability to customize audits and systems to handle a plan's specifics and act as advocates for sponsors with significant financial exposure makes them crucial partners. Generalist firms may have audit expertise but lack an understanding of health and prescription plans and their nuances. It requires well developed medical billing and audit knowledge for accuracy.
