In today's landscape, many large self-funded benefit plans rely heavily on outsourcing for their medical and Rx claims administration. But how were things set up initially? That's where medical and PBM RFP consulting is valuable. Setting up favorable agreements with third-party administrators (TPAs) and pharmacy benefit managers (PBMs) is essential. Given that medical and Rx claims tend to be significant expenses, the demand for auditing services is stronger than ever. These auditors often provide continuous monitoring options, which can enhance the value of their assessments in the long run.

While mistakes in processing might be unintentional, they can accumulate into substantial budget overruns if not identified and corrected swiftly. Auditing practices have come a long way, with many now routinely reviewing 100 percent of claims. This comprehensive approach is a marked improvement over earlier methods that relied on random sampling. As a result, the accuracy of these audits continues to improve year after year. Many benefits administrators find it surprising that these audits, combined with continuous monitoring, can uncover savings that surpass the cost of the services by fourfold.

Auditors' effectiveness has led many plans to adopt auditing as a strategic management process, shifting the focus from a mere compliance exercise to a more proactive, ongoing oversight mechanism. Ensuring that claims are processed accurately and uniformly ultimately enhances coverage for all plan members. Moreover, auditing pharmacy benefits is crucial for ensuring that the balance between generic and brand-name medications is maintained. By reinforcing these guidelines with PBMs, audits help ensure compliance with the formulary. Ultimately, pharmacy benefit plans aim to maximize member care.

For those who have managed in-house plans, the challenges of recovering overpayments after a periodic audit are all too familiar. When older claims resurface for correction, the process can become much more intricate. Continuous monitoring, on the other hand, allows for real-time error detection and prevention, which is more efficient and less contentious. Modern auditing software can run seamlessly in the background during claim processing, quickly flagging any inconsistencies. By reviewing every claim, this method paves the way for significantly improved financial outcomes for the plan.