There might have been a time when health plan auditing services were considered a regulatory and compliance issue without much more consideration. However, that's all changing now as continuous improvement in audit technology and systems has unlocked far greater potential Today, self-funded plan sponsors see the value in frequently auditing their claim payments, if not monitoring them continuously. Since the coronavirus pandemic, the need for closer plan management has been more apparent as an unexpected event can have a significant impact. It's also a way to serve members better.

The need for oversight has grown as claim payment systems have become more complex, and the trend toward outsourcing the function has increased. While its common for third-party administrators and pharmacy-benefit managers to guarantee their performance, only an unbiased, independent audit can confirm it. Large for-profit employers with quarterly earnings reports and facing the scrutiny of analysts and shareholders need explanations for cost increase trends. When medical and pharmacy plans cause increases over budget, the ability to explain them is crucial, and audit data is factual and helpful.

Most TPAs and PBMs handle claim processing for many plans and layer each one onto their existing systems. There are nuances for each, and it's easy for them to fall back on default settings. Auditing that includes your plan's details can verify whether they are being effectively implemented during processing and payments. They can be recommended for correction when systemic errors (or oversights) are detected. Then in the future, the efficiency and accuracy of payments are improved for the long term. Depending on the scope of the anomalies, the cost savings can be significant.

The rise of specialist claim auditors that are fully independent and possess proprietary technology to improve their performance, makes an impact. They have been ahead of the curve in improving the value of audits and providing significant value to their clients. If you've been relying on vendors to self-report or previously given murky reports, things will change when you switch to a better auditor. They can simplify the process, require less of your time, and provide you with easy-to-read reports that quickly bring things into focus. You're set to handle oversight better with the correct data in hand.