Employers that provide self-funded health care plans for their employees have a vested interest in keeping their plans financially sound. It is essential to conduct regular medical claim audits to ensure the plans remain on track. While audits were previously used primarily for regulatory compliance and relied on less accurate random samples, they have become valuable management tools. Present-day auditors meticulously review 100 percent of claims paid, significantly reducing undetected errors and aiding in the recovery of funds. Even the best administrators aren't perfect. 

More frequent audits and monitoring contribute to catching overcharges sooner, making them easier to recover. Advancements in technology have ushered in a new era of claim auditing, benefiting the plans. The trend toward more frequent audits has been further fueled by the increased outsourcing of claim payments and administration to third-party administrators. Plans now require oversight of their work. This need for oversight also extends to prescription claims, with pharmacy benefit managers handling payments and processing. There can be "low-hanging fruit" mistakes in Rx claims auditors can catch.

Conducting audits not only helps identify errors but also improves member services. A specialized group of independent claim auditing firms has emerged, offering expertise in the field that surpasses that of generalist firms in terms of competitive pricing and accuracy. These specialized firms stay up to date with industry trends and developments, providing them with a deeper understanding of medical and pharmacy claims auditing. When choosing a firm to audit your medical plan, seeking out those with specialized expertise and a commitment to helping your company's plans is crucial. 

When initiating a new pharmacy benefit manager (PBM) or a third-party administrator (TPA), scheduling a 90-day implementation audit is essential to ensure they have accurately set up your system. Many plan sponsors have learned the hard way about missed performance guarantees, ultimately leading to time-consuming and costly error patterns. Medical and pharmacy claim costs substantially impact the bottom line, as evidenced during the coronavirus pandemic. Regular audits are essential to ensure the proper functioning of your plan in the short and long run.