Changing to a new third-party administrator (TPA) or pharmacy benefit manager (PBM) is a critical time to conduct an implementation audit. These audits are generally scheduled about 90 days after the transition. Regardless of assurances in service agreements, TPA and PBM auditing services are necessary. The setup of the claims payment system must be thoroughly reviewed, especially given the complexity of many self-funded benefits plans. With major financial stakes and member service quality at risk, a comprehensive, 100-percent claim audit is the most reliable approach.
Implementation audits have become popular due to their positive impact on plan performance. Modern audits apply advanced proprietary software, making electronic review processes more accurate and efficient than ever before. Gone are the days of random sample auditing, which often left gaps in oversight. Today, a full review of all claims is standard practice, allowing all errors and irregularities to be identified. Leading audit firms supplement this technology with expert human review, ensuring the reported data is accurate and that your plan receives every benefit promised by the new TPA or PBM.
The 90-day mark is a strategic checkpoint, providing enough claim payment data to determine if minor alterations or significant corrections are needed in the system setup. Delaying this review can increase the risk of issues and complications if errors exist in the TPA or PBM’s processes. Utilizing independent auditors is recommended, as they are impartial and solely focused on serving your plan’s best interests. Their attention to detail helps ensure that all facets of claim processing meet the standards and promises outlined in your new service agreement. Their day-to-day expertise is also irreplaceable.
After implementation, many organizations choose ongoing monitoring of claim payments. Continuous audits use the same advanced software to unobtrusively track anomalies and irregularities as they arise. This process also makes sure that the claims system remains in sync with your plan’s summary description and covered services. Proactive oversight enables early detection and correction of minor matters before they escalate, supplying peace of mind to senior management responsible for financial stewardship of the benefits plan. It also helps meet the plan’s all-important fiduciary responsibilities.