Benefit Plan Financial Management + Claim Audits

Every health plan, including those self-funded by large employers, has a primary mission: to serve members and ensure they receive the necessary care effectively. However, navigating the complexities of health plans can lead to significant financial challenges if not managed properly. That's why medical claims and PBM auditing services are a key focus, especially following the surge in utilization rates brought on by the coronavirus pandemic. Auditing is essential for health plans to ensure that members receive quality care while also managing costs effectively. It's also wise to audit and monitor Rx claims.

The pandemic has underscored the critical importance of routine auditing. Reports of overcharges and wide price discrepancies for new testing services have made headlines, highlighting the need for thorough oversight. While third-party administrators (TPAs) claim they monitor these situations, we can only verify their promises through rigorous audits and continuous scrutiny of claim payments. Those experienced in managing health plans understand the importance of oversight; without audits, we're left relying solely on what TPAs and PBMs self-report.

Expert claims auditors specialize in this area and can uncover errors and overcharges that often amount to far more than their audit fees, sometimes yielding savings that are four times the cost of the audit. For large nonprofit employers that self-fund their health plans, financial accuracy is crucial. With fixed budgets and limited access to reserves, many faced increased financial strain during the pandemic. When audits are conducted and discrepancies are identified in real time, they can be addressed swiftly, preventing minor issues from escalating into larger financial problems.

Health plans require thorough management to ensure members receive the service they need while safeguarding the sponsor's financial resources. Accuracy in claim payments becomes particularly critical when the specific rules governing coverage are being enforced. Since the inception of self-funded plans, periodic audits were mandated for valid reasons, and it's increasingly evident that these reviews could occur more frequently for everyone's benefit. With healthcare and prescription costs continuing to rise, effective management is not just beneficial—it's essential for the overall functioning of health plans.