Large employers, whether corporate or nonprofit, face significant financial exposure with self-funded medical and Rx plans. The recent pandemic highlighted how unexpected events can lead to sharp increases in healthcare costs. As a result, claim administrator and pharmacy benefit manager audits are experiencing heightened demand, with plans keen to understand their claim expenses. An accurate way to review what was paid is by auditing the claims, which also helps identify any fraud or abuse patterns. It's essential for plans to remain eternally vigilant against such activities.

Thanks to advances in technology, today's auditors analyze 100% of claim payments with impressive accuracy. Given the rising costs of healthcare, relying on random sampling methods is no longer sufficient. It is a crucial moment for plans to tackle fraud and abuse, armed with actionable audit data. By conducting frequent, accurate audits, plan managers can provide executives with a clearer understanding of health care claim expenses, offering peace of mind in a turbulent environment. The capabilities available today would have been unimaginable just a couple of decades ago.

Also, many former executives from major health carriers have transitioned into audit firms, bringing valuable experience with them. This shift has resulted in notable advancements in auditing that often recoup more money for plans than the costs incurred to conduct the audits. Many self-funded plans now outsource their claim payments to third-party administrators (TPAs), typically larger health insurance plans. While these TPAs have advanced processing systems, errors can still occur, and questionable payments may slip through undetected. Audits play a crucial role in identifying errors.

In-house plan managers require tangible data to discuss claim processing accuracy with TPAs, and audits provide it. A growing trend is for plans to utilize the same auditing software for continuous monitoring. This shift signals a new era of accuracy, enabling the detection of errors and irregularities while they are still manageable. Prompt recovery of overpayments is far simpler than waiting one or two years to rectify issues. Additionally, members with high-deductible coverage experience improved service through more accurate claim payments, enhancing their overall satisfaction with the plan.