The Post-COVID World and Auditing Benefit Claims

The landscape of healthcare management has shifted dramatically in the years following the coronavirus pandemic. Some practices have fallen by the wayside, while others have gained newfound importance. One area that has become increasingly vital for large employer health plans, particularly self-funded plans, is medical claim and PBM audits. The pandemic spurred a surge in claim volume, leading to staggering overcharges. While third-party administrators (TPAs) and pharmacy benefit managers (PBMs) identified discrepancies, continued close claims auditing is essential for optimal plan management.

Well-managed plans that prioritize fairness for members and cost control recognize the need for frequent audits. The trend of outsourcing claims processing to TPAs has introduced efficiencies and enabled plans to benefit from health carriers' expertise. However, this shift has also distanced plans from direct oversight of their claims. Despite TPAs' performance guarantees, potential errors and overcharges can still evade detection. For instance, some services are billed at inconsistent prices, with many exceeding what would be deemed reasonable and customary.

Despite the challenges posed by rising medical and Rx costs, today's auditing technology has kept pace remarkably well. Many firms now routinely review 100% of claims, achieving an impressive level of accuracy. If your TPA has overlooked specific issues, hiring a competent auditor can help bring those oversights to light. Independent auditors specializing in medical claims have the necessary expertise and can conduct reviews efficiently, requiring minimal involvement from your in-house team. The return on investment can be substantial, with audits and monitoring recovering costs as much as four times over.

If you're managing a self-funded medical and pharmacy benefit plan and haven't yet implemented continuous monitoring of claims payments, now is the time to do so. A monitoring service leveraging advanced audit software will provide you with real-time insights. You'll be alerted immediately to any spikes in utilization or increased error rates. Continuous oversight means your TPA's performance can improve when they know you're engaged in the process. As expectations for management continue to rise, monitoring your claims will empower you to perform your role more effectively.