Making Healthcare Claim Payments More Accurate

Claim payment accuracy is crucial for benefit plans offered by large employers. Recently, medical and Rx claim auditing services have gained more attention, even starting as early as PBM RFP consulting, as many organizations began to uncover irregularities in their claims. Some of the discoveries are quite shocking, revealing significant overcharges and billing inconsistencies. Managing financial controls over self-funded plans is already complex, and the current environment has made it even more challenging. Often, the only way to sort through the confusion left in its wake is through post-event audits.

One area where claim reviews frequently highlight issues is in pharmacy plans. A key focus is the comparison between generic and brand-name medications. Pharmacies can easily end up dispensing more expensive name brands when there are less costly generic alternatives available. Regular audits that track these instances remind pharmacies about the importance of adhering to the formulary. When you see the savings generated by strictly following generic medication guidelines, it becomes clear that audits serve a vital function beyond just regulatory compliance; they offer substantial financial benefits.

When it comes to contracts with third-party administrators for medical and pharmacy benefits, these agreements often include performance guarantees. However, if these administrators only rely on self-reports without independent verification, they might miss critical errors. Their internal audits might use the same systems that produced the mistakes, which can lead to misleading results. Bringing in an external auditor can uncover discrepancies that internal teams may overlook. Plus, knowing that an external reviewer is monitoring the process often encourages better practices among staff.

Choosing the right claim audit firm is also essential. While you might have an established relationship with a generalist auditing firm, it\'s worth considering whether they have the specialized expertise needed for medical and prescription claims. Expert claim auditors can provide deeper insights and recommend system improvements that lead to greater cost savings. The importance of effective auditing in the management of benefit plans, especially in Rx claims, cannot be overstated. Thorough, independent audits not only help identify potential savings but also enhance overall financial integrity.