Auding employee health plans sponsored by large corporate and nonprofit employers is crucial for controlling costs and ensuring consistent service for members. Doublechecking third-party administrators and pharmacy benefit managers with a medical or Rx audit helps provide necessary oversight for plan sponsors. Transferring claim administration control can bring cost efficiencies and expertise but may also lead to a lack of direct oversight by the plan sponsors over the payments. Claim auditing then becomes a vital tool for plan sponsors to restore an element of oversight and control.
Auditing health plans involves assessing the accuracy of claims and depends on several factors, which can vary between medical and pharmacy plans. For instance, in the medical claims review, auditors need to verify the charges submitted by doctors, particularly for services that appear to be excessively priced. Additionally, they need to compare test costs against the reasonable and customary standards of the National Correct Coding Initiative. It involves examining code pair tests that should not be reported together, as one test may negate the need for the other – and the occurrences are surprisingly frequent.
By flagging overcharges, a plan sponsor can position themselves to recover overpayments from medical providers, ultimately totaling more than the cost of the audits. Similarly, when auditing pharmacy claims, auditors must ensure that the plan formulary covers medications dispensed. Furthermore, drug utilization reviews can help to ensure members receive the appropriate medications that align with the covered plan formulary. Paying attention to these small but significant factors is crucial for cost efficiency, and audits play a key role in identifying irregularities that occur and need correction.
Timely auditing offers numerous benefits, including improved success in recovering overpayments and enhanced plan oversight. Advancements in software and technology have facilitated quicker and more accurate reviews of details. It has allowed audit data to continue to improve, adapting to the specific needs and nuances of medical and pharmacy benefit plans, which require review based on different criteria. Given the rising costs of medical care and the financial pressure faced by plan sponsors, the need for frequent auditing will only increase over time to effectively manage and control costs.
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