As the scope and price of medical services and medicines continue to strain medical and pharmacy benefit plans, audits help them keep up. Today medical claim auditors consider an ever-widening number of covered services and medications – plus the negotiated prices, acceptable maximums, and rebates that can come with them. The claims third-party administrators and pharmacy benefit managers pay today for more numerous and complex. It increases the need for oversight and reconciliation more frequently. Errors and discrepancies need to be caught and corrected sooner and more thoroughly.


As auditors begin reviewing medical and pharmacy claims, they first verify the eligibility of each person who received a covered service. Next, their electronic reviews go through invoices line by line to confirm that the charges don't exceed contracted rates or reasonable and customary limits. It's routine to uncover duplicate charges and flag them for straightforward recovery. Advanced software can reconcile invoices to ensure they are totaled correctly and watch for administrative fees that TPAs or PBMs may have tacked on. When claim volume is high, there are significant financial opportunities.


Other significant parts of medical and pharmacy benefit claim auditing are reviewing various cost-sharing arrangements with plan members. They can also check payments per member to confirm plan limits are being observed when they exist. It makes sure all members are treated fairly, and some are not allowed to receive more services than others. Coordination of benefits opportunities should not be overlooked, and sometimes PBMs and TPAs skip them to save time and effort. In nearly all agreements today, there are performance guarantees. But are they being met? If not, follow-up is necessary.


The most important thing to keep in mind is the level of accuracy available in today's 100-percent audits. What they could cost-effectively achieve was impossible with the prior random-sample methods. The firms that specialize in claim auditing and make it their only business are the ones driving the change – and improvement. They are never content with the status quo, and they update their proprietary software and methods to serve their clients better. The sums routinely recovered by precise audits are impressive and, for many plans, help them stay on track financially. Don't miss the opportunity for yours.