Self-funded medical and pharmacy plans offered by mid and large-sized corporate and nonprofit employers provide excellent employee benefits but represent a considerable financial liability. This highlights the importance of running a medical and Rx audit to review claims and ensure they are being accurately processed and paid. Today's auditing "best practices" review all claims instead of relying solely on random samples. Initially established to comply with ERISA and Sarbanes-Oxley regulations, these audits have become crucial management tools for both cost control and plan performance.

Government, municipal, and educational institutions with self-funded medical plans can similarly gain from the robust auditing and monitoring services utilized by for-profit organizations. Anyone overseeing a self-funded plan should explore the advantages of comprehensive audits and ongoing claim payment monitoring. Just a couple of examples showcasing improved performance can illustrate the potential benefits. For instance, pharmacy benefit plans often emphasize the use of generic medications—ensuring that the claim administrator adheres to medicines on the formulary is wise and essential.

As the duties of in-house benefit plan managers expand, enhanced auditing and monitoring become vital for performance improvement. Concrete data regarding claim payments boosts credibility and helps manage plan costs and claim processing. Leading discussions with solid data can expedite the resolution of systemic errors through collective agreement. In addition to managing expenses and performance, improved claim processing accuracy can also benefit members with high-deductible plans, illustrating the multiple advantages of more precise auditing. It’s a definite member service upgrade.

Many companies opt for ongoing auditing monitoring to leverage today's advanced claim auditing technologies. It ensures claim payments are assessed in real time, allowing for immediate reporting of errors. This proactive method effectively prevents more significant issues by identifying mistakes early, saving money, enabling systemic changes to avert future errors, and simplifying the recovery of overpayments. The service typically remains budget-neutral or better and receives high approval ratings from organizations currently utilizing it. There's a significant improvement over random sampling.