Getting Claim Administration Running Smoothly

Conducting an implementation audit 90 days after establishing new health and pharmacy claim processing systems is important for plan sponsors. Independent medical claim auditing services can confirm that third-party administrators (TPAs) and pharmacy benefit managers (PBMs) have configured their systems accurately. Early audits are the most effective way to identify minor errors before they worsen into expensive, large-scale problems. While TPAs and PBMs may provide performance guarantees, only a thorough audit of all claim payments can truly validate their commitments.

Experienced auditors recommend waiting 90 days for an implementation audit, as this allows enough claim activity to provide a meaningful overview of performance. Auditing too early yields incomplete data and limits the ability to detect system-wide problems. On the other hand, delaying audits can result in errors that might have been addressed if caught sooner. Reputable TPAs and PBMs welcome audits as opportunities to upgrade their processes; resistance to auditing points to underlying performance concerns. For plan sponsors, verifying accuracy through auditing is essential to protecting their interests.

During implementation, audits excel at pinpointing inaccuracies in a plan’s set-up, especially within the larger, complex environments managed by TPAs and PBMs. Because each client’s requirements are unique, programming those nuances into large systems can be challenging, and even diligent efforts can leave room for errors or omissions. Early claim audits that identify issues enable timely corrections, preventing small variances from becoming costly problems later. Given the serious financial exposure associated with health plan claims, early detection and resolution are critical for long-term plan success.

For large, for-profit employers with thousands of plan members, medical and pharmacy claim costs impact quarterly financial results and shareholder perceptions. Unexpectedly high claim expenses can raise doubts during analyst calls and affect the organization’s financial standing. As a result, many plan sponsors now audit claim payments more frequently than regulations require, using audits as proactive management tools to control costs and acquire insights. It stresses the value of implementation audits and explains why many organizations also invest in ongoing monitoring services after the initial review