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Employer-sponsored health plans cost a lot of money, and it's no wonder medical claims auditing is an increasingly sought-after service. But given prescription medication costs, many of which are astronomical, keeping close tabs on pharmacy benefit plans is equally crucial. Audits need to be specialized and double-check accuracy for a unique set of criteria for medications. In some cases, it's more straightforward than medical claim reviews, but it does have nuanced and requires expertise on the auditor's part. Specialist firms have grown in prominence because they do the most effective job.

It's commonplace these days (and an excellent idea) to check 100-percent of pharmacy claims paid. Improved technology makes it possible to do in less time than random samples. If you've been in the plan administration field for a while, you undoubtedly recall being impressed by the first 100-percent audits. Today, it's possible to work up to higher standards of accuracy and keep close tabs on pharmacy benefit managers. It makes sense to outsource claim processing, but oversight is vital when management responsibilities lie with a third party. Catching and correcting mistakes helps the bottom line.

Claim audits are an easy sell to senior management because they lead to more recoveries than they cost. For many plans, the ratio of recoveries to price is four times. It adds up quickly for large plans and managing claim processing more closely benefits everyone. Members with high deductible plans are helped the most by accurate claim processing. It also meets regulatory requirements and generally improves member service. Plans that weren't closely audited had many more claim payment irregularities during the coronavirus pandemic, and the numbers were significant.

Name-brand medications versus generics are one of the most basic cost-saving opportunities for any prescription plan, and are formularies being followed precisely? An auditor can say yes or no and flag the mistakes. Correcting them can reduce costs immediately while making no quality compromise for members. Processors will take accuracy more seriously when there is routine oversight. Even those that are highly accurate and careful can let things slip through the cracks. When you correct them, your pharmacy plan will be better managed. It serves members better and meets fiduciary responsibilities.



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