Using medical claim and PBM auditing services is an important strategy for company-funded medical and Rx plans. Professional claim auditors thoroughly examine every facet of service delivery and payment processes. Counting solely on occasional audits can cause missed opportunities to consistently improve performance. For large corporations and nonprofit organizations that self-fund their medical and pharmacy claims, substantial sums of money are at stake. With ongoing cost increases and unpredictable events, routinely verifying claim payments with a comprehensive audit is a wise practice.

Certain third-party administrators might attempt to avoid audits by including contractual clauses or by assuring clients of minimal error rates. However, regardless of their performance or the strength of your relationship, independent oversight is important. Errors in claim processing may be due to human error or system-wide issues, with the latter often recurring undetected unless addressed by a different perspective. Auditing firms specializing exclusively in claims have developed advanced software able to identify even the most slight discrepancies, offering impressive accuracy and reliable results.

Effective claims auditing also demands specialized medical knowledge. Auditors focused solely on financial or tax matters may lack the detailed expertise found in those with direct health carrier experience. When selecting an auditing firm, inquire about their team’s qualifications to ensure you receive the best possible service. Opting for a 100-percent review of all claims, rather than relying on random sampling, leads to more thorough results. While some may advocate for sampling, experience and common sense confirm that only a complete review provides the necessary attention to detail.

If previous audits or internal insights have revealed areas that need improvement, communicate these priorities to your auditor. While auditors are skilled at identifying most errors, requesting targeted data or more detailed reporting on certain topics can provide further value. Experienced claim audit firms apply their extensive knowledge and best practices to every project, making sure clients benefit from their expertise. Notably, audit reporting has become much more accessible in recent years. Reports are now written in clear, plain language that plan managers can easily understand and act upon.