The complex world of medical claim payments is starting to grab headlines, particularly as large self-funded plans take legal action against their claim administrators, typically big-name health insurers. This trend is likely to motivate more self-funded plans to conduct thorough healthcare and PBM audits to review their claim payments. It may sound unusual, but in business, it's common for one company to hire another to manage their payments—especially for health and Rx claims. In the past, self-insured some large employers handled claims directly, but outsourcing has become the industry standard.

Outsourcing to major health carriers allows self-funded plans to tap into established provider networks, infrastructure, and expertise. These carriers are generally contracted with the promise to manage the healthcare expenses incurred by the self-funded plans effectively. They typically guarantee that error rates will remain extremely low. To ensure these promises are met and that claims are handled appropriately, auditing serves as a crucial safeguard for plan sponsors. Even plans that seem to operate smoothly may contain discrepancies that an audit can uncover, highlighting the value of regular reviews.

Recovering overpayments is a concern for health and pharmacy plan sponsors. When mistakes happen, there's often a pressing question: Is the money lost for good, or can it be reclaimed? It emphasizes the importance of timely auditing. By reviewing payments, errors can be identified and corrected sooner, potentially saving thousands or even millions of dollars. Having experienced claim payment reviewers is crucial in this process. Fortunately, some firms specialize in audits and medical billing, and their expertise enables them to identify potential discrepancies.

If you're managing a self-funded plan and are transitioning to a new processor—whether it's for medical, pharmacy, or other benefits—it's wise to initiate an implementation audit. The consensus is that the best time to do this is generally about 90 days post-implementation. By this point, enough claims will have been processed to evaluate accuracy and identify areas needing improvement. Each plan consists of numerous unique provisions that must be accurately reflected in the system for successful claim payments. Sticking closely to the established guidelines is essential for accuracy.