The oversight function of auditing is crucial to anything involving financial transactions, including health and pharmacy benefit plans. Their claim payments are a significant financial exposure for the plan sponsors, and keeping tabs on them is needed. As a result, medical claims auditing has a considerable role in good plan management, balanced service to members, and cost control. Auditors today have advanced software that reviews 100-percent claims down to a minute level of detail. The result is a level of accuracy never before seen, and plans are reaping the benefits of a new strategic management tool.

The previous random sample method often entailed more human intervention (eating up staff time) than today's 100-percent claim audits. It's because the systems and software have become so much more capable and precise. When auditors give their results with professional human oversight, the accuracy and level of detail are unmatched. It's changed the game for claim auditing because what began as a compliance issue has evolved into something more. The price of an audit is often less than a quarter of the funds it recovers. These are eye-opening realities that have caused plan sponsors to sign on.

What needs to be checked in medical claims varies from the priorities with prescription claims, but the financial opportunities are significant. Auditors with advanced software and systems can quickly review any processor's approach with a minimum of complication. Specialist firms have executives with experience at large health plans and know their systems well. It speeds up the process and makes the audit results more reliable. The same firms are known for clear reports that aren't difficult to understand. It saves time and improves the efficiency of the in-house staff who work directly with TPAs and PBMs.

Given the success of today's auditing, a recent addition from some firms is a continuous monitoring service. It keeps the auditor's software running continuously in the background and flags irregularities in real-time. It's an asset for well-managed plans and further improves their performance. For plans that have not been monitored, it's a revelation about the achievable cost savings and member service improvements—for large corporate employers reporting earnings and concerned about stock prices, having monitoring during extraordinary events such as the coronavirus pandemic adds accountability.