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Professional Group

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Why Implementation Claim Auditing Matters


Medical claim auditing is an essential oversight tool for large employers' self-funded medical and prescription plans. When plans begin with new processors, such as third-party administrators for medical claims and pharmacy benefit managers for prescriptions, implementation auditing becomes crucial. While TPAs and PBMs have significant experience and expertise in the field, adding a new project to their systems requires getting thousands of details right. Auditors can definitively verify the accuracy of the setup. It's vital that your plan's provisions are compared against the initial payments.


Planning an implementation audit for 90 days after a new claim processor takes over is common. By then, there is enough experience to make it worthwhile, and it's early enough to catch significant issues before they become major problems. Implementation audits also ensure that member service goals are met and analyze other functional aspects of claim processing. The data from audits are concrete and cannot be easily disregarded. After the implementation phase is complete, many plans consider a continuous monitoring service from the same firm using the same software for "best practices." 


This real-time review of claim payments allows for thorough oversight of TPAs and PBMs, ensuring that plan sponsors stay fully informed of their claim payments and experience separate from the processors' reporting. This helps to detect trends early and address them when they are smaller. Independent specialist auditing firms are the most efficient in setting up implementation audits that leave no stone unturned. They review every claim and consider dozens of factors, resulting in an audit report covering even minute details of the processing setup. It either confirms accuracy or points out mistakes.


Implementation claim auditing is the best way to ensure that TPAs and PBMs meet their accuracy guarantees and that claims are paid as specified in the plan documents. When the processing setup is accurate and functioning, members are well served, and costs are controlled to the best extent possible. Members also benefit and are treated more fairly when claims are paid accurately. When there is a mistake, it may favor one or some members over others. Plan rules require everyone to be treated fairly and given the same treatment and coverage. Keeping tabs by auditing is the best way to run oversight.

 

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