Medical claim auditors provide the most effective oversight mechanism for large employers managing medical and prescription plans. This emphasizes the importance of conducting implementation audits when new processors come on board—namely, third-party administrators (TPAs) for medical claims and pharmacy benefit managers (PBMs) for prescriptions. While TPAs and PBMs often have considerable experience, integrating a new project within their systems requires meticulous attention to numerous details. Auditors play a critical role in validating the accuracy of this setup to your plan’s provisions.

Typically and optimally, an implementation audit is scheduled for 90 days after a new claims processor starts their role. By this point, there is enough operational data to make the audit beneficial, while it’s still early enough to identify any significant issues before they escalate into costly problems. Addressing overcharges and erroneous payments is more manageable soon after they occur, rather than waiting months. Additionally, implementation audits ensure member service goals are met and assess other aspects of claim processing. The findings from these audits are substantial and not easily overlooked.

After the implementation phase, many plans opt for ongoing monitoring services from the same audit firm using consistent software tools. This ongoing review of claim payments in real-time allows for effective oversight of TPAs and PBMs. Plan sponsors remain informed about their claim payments and performance, independent of the processors’ reports. A proactive approach helps prevent unexpected developments and keeps operations on course. It’s common for high costs to accumulate over time due to trends, and early monitoring can help identify these trends quickly for timely intervention.

Independent auditing firms specializing in this field possess the expertise and systems necessary for efficiency. They conduct thorough implementation audits that scrutinize every claim against dozens of factors. The outcome is a detailed audit report that covers even the smallest aspects of the processing arrangement. This is the only reliable method to ensure TPAs and PBMs adhere to their accuracy commitments and that claims are paid according to the specifications laid out in the plan documents. When the processing setup operates correctly, members benefit, and costs are maintained effectively