When health and pharmacy plan sponsors switch to a new third-party claim administrator or pharmacy benefit manager, it's vital to schedule an implementation audit at the 90-day point. You need independent verifications that claim payments are off to a smooth start and your plan's interests are managed well. New TPA and PBM relations customarily come with many promises about better service – but the only way to know if it's happening is to audit. It's also crucial to review 100-percent of claims with sophisticated audit software capable of picking up each detail. It's a complex process. medical claim auditing services.
If you're deciding about timing, veteran claim auditors have found that 90 days is the ideal point for the implementation review. It's before any error patterns have become million-dollar problems and long enough after the start for there to be sufficient data. TPAs and PBMs have complex systems required by the fine details of claim processing, and your plan has its specific description. Making sure your parameters are added to their system correctly requires careful auditing. Even if your service agreement has accuracy guarantees, only an independent claim audit will verify them. It's your budget and plan on the line.
When expert auditors flag set up issues, there's no debate about what's happening. It's concrete oversight data you can use to bring quick action and corrections. Even when TPAs and PBMs have a plan's best interests at heart, it's not always a simple process to program every detail into their systems – and their internal oversight runs on the same system and may miss what an auditor picks up. Today's claim audit software is more sophisticated than ever, and it instantly picks up things you'd be surprised it could detect. Errors tend to repeat and become ever more costly, which can cause budget issues.
Most self-funded employer benefit plans cover large groups of employees. It's why small mistakes can become significant issues given the plan's size. There are also more significant opportunities for savings when claims are paid accurately and agreements honored. Once you are up and running and past the implementation audit phase, you may want to consider continuous monitoring. It runs on the same software and gives you real-time updates about your claim payments. If there are errors or changes, you can recover overpayments more quickly and with fewer questions than when they are long in the past.