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For large corporations and nonprofit organizations that self-fund their employee benefit plans, regular medical claim and PBM auditing services are a valuable tool. With most claims processing now handled by third-party administrators and pharmacy benefit managers (PBMs), verifying payment accuracy becomes crucial. A skilled, independent auditor can provide objective feedback, either confirming that processes are working smoothly or highlighting areas that need attention. Even with diligent third-party administrators, mistakes and irregularities can still occur, making a second set of eyes indispensable.

Technological advancements have raised the bar for managing many aspects of business, and medical and pharmacy claims are no exception. Considering the large sums of money involved and the risk of errors, it’s no surprise that audits often recover many times their cost by identifying overpayments. Rather than relying on random sampling as was done in the past, most organizations now review every paid claim. Sophisticated electronic systems and specialized software make this possible, and these tools are continually improving, allowing for even closer monitoring year after year.

Pharmacy benefit plans also present unique challenges, largely revolving around which medications are covered (the formulary) and the frequency and recipients of those prescriptions. Today’s systems are designed to promote cost-effectiveness by requiring the use of generics when available and setting refill intervals that match the prescribed dosage. Still, errors can occur—especially in large plans covering thousands of people. Even a small percentage of mistakes can result in significant financial losses. By regularly auditing Rx payments, organizations can spot unusual patterns or excessive dispensing.

Ultimately, the purpose of any employee benefit plan is to deliver on its promises to members as efficiently as possible, particularly given the high cost of healthcare today. Having reliable, independent data on claim payments is invaluable, especially for organizations that directly oversee an outside claims processor. Facts and figures strengthen your position in negotiations and make it easier to drive necessary changes with data. When unexpected events arise—such as a global pandemic—a well-managed plan with oversight ensures you can adapt quickly and maintain control.