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In the post-pandemic world, the importance of auditing health plan claims is evident. Large corporate and nonprofit employers that self-fund plans faced significant financial impacts during the pandemic, and many continue to do so. To navigate the complex environment, running a TPA and PBM audit is critical for identifying overpayments and correcting errors. However, it requires different strategies for Rx and medical claims, making it essential to have specialists dedicated to these fields. Their understanding of the unique aspects of each type of claim allows them to identify issues effectively.

When it comes to medical claims, accuracy relies on collecting detailed information and employing robust software to analyze large amounts of data swiftly. Auditors need to pay particular attention to the physician's charges, ensuring they align with what is considered reasonable and customary for the services rendered. The same scrutiny applies to lab tests, where auditors must verify that charges meet the standards set by the National Correct Coding Initiative. Additionally, they should be able to identify pairs of tests that should not occur together, as one often negates the necessity of the other.

Pharmacy claims follow a distinct set of criteria. Each plan has its formulary, and ensuring that providers adhere to it is crucial. A significant issue arises when costlier brand-name medications are dispensed when lower-priced generics are available. Skilled auditors can quickly spot instances of early refills and prescriptions exceeding quantity limits. They play a vital role in conducting drug utilization reviews that encourage pharmacy benefit managers to guide members toward approved medications, thus promoting cost-effective choices. By identifying irregularities, auditors help the plan's bottom line.

Conducting periodic, if not frequent, claim audits delivers numerous benefits. There's no substitute for reviewing the output of claim administrators and recovering overpayments. Delaying this process can complicate matters. Maintaining ongoing monitoring is a more effective solution, and many now advocate for continuous auditing services. Having auditing software running in the background not only proves to be cost-effective but also streamlines plan management. For those interested in maximizing the potential of their claims, reaching out to auditors can reveal a wealth of benefits worth exploring.