Get Ready for Claim Audits Keep Health Plans on Track

Large corporations and institutional employers that self-fund their health insurance plans frequently face substantial, recurring cost increases. While some escalation in expenses is inevitable, robust medical claim and PBM auditing services play a critical role in mitigating these rises by identifying errors and uncovering overcharges. Today, the majority of self-funded plans delegate the administration of claims payments to third-party administrators (TPAs), making diligent oversight through systematic auditing and monitoring of payments an essential component of effective plan management. 

Audits of employer-funded medical and pharmacy benefit plans consistently yield savings that exceed the cost of the services themselves. Ongoing monitoring, particularly when applied to 100 percent of claim payments, yields significant returns by ensuring all claims are scrutinized before payment. During the COVID-19 pandemic, these practices proved invaluable, helping many organizations manage unforeseen testing and treatment expenses. For many plans, this period set new records for both the volume of claims and the financial impact, underscoring the importance of rigorous oversight.

Although the primary motivation for conducting audits is often to rein in escalating medical expenses, these efforts also directly benefit plan members. Individuals with high-deductible health plans, in particular, appreciate the accuracy of claim payments and administrative processes that result from rigorous oversight. Real-time claim monitoring allows errors and discrepancies to be identified and addressed immediately. Leveraging advanced audit software in real-time enables organizations to detect emerging error patterns quickly, preventing small issues from developing into costly problems later.

As organizations seek to optimize every aspect of their operations to control expenses and bolster financial performance, expectations for oversight continue to rise. Senior leadership increasingly expects in-house managers to leverage advanced tools, such as claim audits, to ensure the highest standards of accuracy and accountability. Reviewing each claim and payment delivers excellent oversight, enabling early detection and correction of errors or systemic issues. Addressing problems promptly reduces financial risk and supports the overall integrity and sustainability of self-funded health plans.