The trend for many years among larger employer-funded benefit plans has been to outsource claim processing. Large insurance carriers handle it with sophisticated capabilities amid promises of cost savings excellent results. But only a healthcare claims audit can verify if the commitments are being met and every opportunity for efficiencies leveraged. The third-party administrators providing the processing services customarily make performance guarantees and offer to self-monitor. It still does not reduce the need for independent auditing to verify the results; the audit report will demonstrate its importance.

One of the most significant opportunities for audits is to tighten up claim processing and prevent mistakes centers of plan specifics. Since each one is layered onto a more extensive claim processing system, some of its unique features may be missed in favor of defaults. If they relate to a member population specifically, overlooking them may miss opportunities. Audits that are set up with a plan's summary description entered meticulously can flag those items, and they can be corrected. It's not a stretch to see that the opportunities are considerable with a high claim volume. Members also are well served by accuracy.

Pharmacy benefit managers aren't immune from errors, and some of the audit findings with their work can add up quickly. Nearly every plan stipulates that generics be dispensed when available, but it's common for expensive name-brand medications to turn up. A claim audit will catch them immediately and help sponsors stop the practice. It's human nature to respond to oversight, and when providers know there is active plan management, they are more likely to follow the rules. The same goes for TPAs and PBMs that improve their accuracy. Many times they only need to make a system edit to fix errors.

It's become standard practice for employer-funded healthy and prescription plans to audit themselves more often than regulators require. It's because the audit accuracy gains have shown they are excellent management tools. The coronavirus pandemic drove home the point farther after unbelievable overcharges in some areas during the early days. Audit reports helped recover some of the excessive charges or prevent them from continuing. Continuously monitoring claim processing and payments is in force at an increasing number of companies. It finds and flags mistakes in real-time to control costs.