Technical fields often have their own unique language, which can make it difficult to communicate the value of their work to those outside their specialty. In medical claim and PBM audits, providing clear, concise, and easy-to-understand reports not only increases the usefulness of the audit but also makes it easier for organizations to act on findings. Advances in technology now allow for the review of 100 percent of claims, making electronic audits more effective than the random sampling methods used in the past. When audit results are presented in a easy-to-read format plan sponsors can correct errors.
Once a claim review is complete, the first step is often to identify and fix systemic errors. However, with comprehensive audits that review every claim, even individual mistakes become worth addressing, since they can add up to significant sums. The audit process is most effective when data is quickly extracted from reports and acted upon right away. Timing is also crucial—today, most large employer plans conduct audits more frequently because auditing has become more cost-effective. Audit firms now manage much of the process themselves, further reducing the workload of in-house staff.
Depending on the complexity of your claims administration and your organization’s experience, continuous monitoring of payments may be beneficial. Auditors can run software in the background, generating monthly reports that provide ongoing oversight. This continuous review is widely regarded as one of the best ways to prevent minor issues from growing into significant, costly problems. Experts in funds recovery agree that requesting corrections soon after an error is discovered is much easier than trying to recover funds months or even a year later, when the process becomes far more complicated.
It’s also essential to schedule an implementation audit when transitioning claim processing to a new third-party administrator or pharmacy benefit manager. The best time for this audit is typically around 90 days after the transition. Waiting longer could allow more significant problems to develop, while auditing too soon might miss issues that have yet to surface. Reports from an implementation audit should be as clear and actionable as possible. This is the ideal time to meet with your claim processor, discuss necessary improvements, and agree on a plan for implementing changes.
