A company’s medical and Rx plans are often the cornerstone of its employee benefits package, and for those with self-funded arrangements, it represents a substantial financial risk. This reality has led in-house managers to maintain closer oversight of their third-party claims administrators (TPAs) than ever before. One effective strategy for ensuring claims are paid accurately and in accordance with plan provisions is to schedule regular medical claim and pharmacy benefit manager audits. Given that errors or overcharges can escalate rapidly if left unchecked, timely detection and reporting are crucial. 

Over time, advancements in auditing technology have shown that self-funded plans could greatly benefit from regular audits, resulting in cost savings and improved plan management. Today, leading auditors routinely review 100 percent of claims, leveraging sophisticated software platforms for continuous oversight. These audit and monitoring services are typically cost-effective, as the value of identified and recovered errors frequently surpasses the expense of the audit itself. This proactive approach also ensures company leadership of clarity regarding health plan expenditures.

Continuous claims payment monitoring is a valuable tool, providing real-time data on a health plan’s costs and disbursements. Immediately identifying and correcting errors, accompanied by detailed explanations of the underlying causes, is a significant advantage over waiting for annual audits. In today’s business landscape, where the stock market demands steady profitability, companies must keep a close eye on every expenditure. Employee benefit programs, including medical and pharmacy plans, can have a major financial impact and influence quarterly earnings significantly at times.

The pandemic further underscored the importance of claims monitoring. Reports of exorbitant charges for routine services, such as diagnostic testing, highlighted the risks. Organizations with continuous monitoring protocols in place were able to swiftly identify and dispute questionable charges, thereby protecting themselves from unnecessary expenses. In contrast, companies without such safeguards found themselves unprepared and vulnerable to financial surprises. In an environment where change can occur suddenly, the value of a well-managed, tightly controlled health care plan is clearer than ever.