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Health and pharmacy benefit plans are intricate systems, and the claims paid on behalf of members can be complex. Over the years, the costs of medical and Rx claims have steadily risen, prompting plans to utilize medical and PBM auditing services for oversight. The scrutiny is necessary, especially as more organizations choose to outsource their claim administration to third-party administrators (TPAs) and pharmacy benefit managers (PBMs). With this shift, claims payments often fall outside the direct oversight of in-house staff, creating a greater need for effective auditing and oversight.

The issue of rising healthcare costs is always a significant concern, but the pandemic intensified this focus. It led to higher utilization rates, new diagnostic tests, and various expenses, putting financial pressure on all health plans, including those that are self-funded. To address these challenges, it’s crucial to ensure claim payments are accurate and to identify mistakes as they occur. It is where a continuous claim monitoring service proves invaluable. These services, offered by audit firms using specialized software, enable rapid reviews of claims, allowing for the efficient analysis of 100% of them.

When a health plan audit examines all claims and generates reliable, actionable data, it serves as an excellent tool for oversight and management. Continuous monitoring keeps the in-house management team informed about ongoing claims processing and helps swiftly identify and correct errors before they escalate into significant issues. Good management practices rely on timely and accurate oversight. The evolution of audit software began in the ’90s and has continuously improved ever since. Modern programs used by auditors in the medical and Rx benefits offer remarkable speed and precision.

When these electronic reviews are supplemented by human oversight, virtually all irregularities can be detected. Independent auditors approach their work from the perspective of the plan, ensuring all details are accounted for. If a TPA operates routinely without adjusting to the specifics of the plan, it risks missing key information that could lead to increased costs due to medical expenses. Self-funded plans that incorporate continuous monitoring consistently report more favorable outcomes over time. This proactive approach to claims management is essential in today’s challenging healthcare landscape.

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