Implementation Claim Audits are a Must
Medical claim auditors provide the most effective oversight mechanism for large employers managing medical and prescription plans. This emphasizes the importance of conducting implementation audits when new processors come on board—namely, third-party administrators (TPAs) for medical claims and pharmacy benefit managers (PBMs) for prescriptions. While TPAs and PBMs often have considerable experience, integrating a new project within their systems requires meticulous attention to numerous details. Auditors play a critical role in validating the accuracy of this setup to your plan’s provisions.
Typically and optimally, an implementation audit is scheduled for 90 days after a new claims processor starts their role. By this point, there is enough operational data to make the audit beneficial, while it’s still early enough to identify any significant issues before they escalate into costly problems. Addressing overcharges and erroneous payments is more manageable soon after they occur, rather than waiting months. Additionally, implementation audits ensure member…