Given the complex claim payment systems used by large health and Rx carriers, it’s understandable that most employer-sponsored health plans choose to outsource their claims processing. However, it is necessary to seek an independent assessment from medical claims and pharmacy benefit manager audits after engaging a new administrator of PBM. Best practice is to conduct an audit around 90 days after the transition. Auditing too soon can yield incomplete results, while delaying allows errors to accumulate. Even when performance guarantees are in place, an audit is an advisable safeguard.

Large corporate and nonprofit employers that self-fund medical and pharmacy plans have considerable financial exposure. Regular auditing helps ensure claims are managed accurately, directly impacting a plan’s financial well-being. The value of frequent audits is evident; most organizations recover more in savings than the cost of the audit itself. Often, audits have uncovered overpayments and recoverable errors worth up to four times the audit’s fee. Leadership teams and stakeholders increasingly expect strong oversight of health and pharmacy benefits, making claim audit services a strategic asset.

Well-timed auditing can be further strengthened with continuous claims monitoring, an increasingly favored option among self-funded plans. This approach uses audit software to track claims activity in real time, with monthly reports provided to plan sponsors for review. Such ongoing oversight allows sponsors to quickly identify and address errors or problems, improving accuracy while reducing unnecessary costs. Real-time monitoring minimizes the impact of mistakes and supports cost control. As demonstrated during the pandemic, plans with strong oversight do better with managing expenses.

Another key factor in claim auditing is the expertise of independent specialist audit firms. These firms have extensive experience auditing all major claim processors. Their leadership teams often include professionals with backgrounds in health plan management, financial analysis, and medical coding, providing a depth of knowledge rarely found in larger, multi-purpose audit firms that focus primarily on finance or tax. Choosing the right timing for your audit and partnering with a specialized firm can deliver the best results, guaranteeing your plan runs well and cost-effectively.