If you're in-house at a large company sponsoring a health and pharmacy benefit plan and trying to decide among medical claim auditors, ask about technology. Many specialist firms in the field have advanced (and proprietary) software that gives them an edge. Their systems can efficiently and cost-effectively review 100-percent of your plan's claim payments and check each one for hundreds of data points. Medical and prescription plans are complex and detailed, and only those with expertise and suitable systems can audit with greater accuracy. Generalist audit firms can't always compete.

Claim audits are essential to regulatory compliance and fiduciary responsibilities. But they are also highly effective oversight tools to be sure your third-party administrator and pharmacy benefit manager are performing as promised. Most make accuracy guarantees, but it's much wiser to let an independent auditor verify those than let the firms police themselves. The coronavirus and the extraordinary costs and spending it triggered were an excellent reminder about the imperative of close plan management. The cost exposures for medical and pharmacy claims are enormous, and you need to monitor spending trends.

The advanced claims auditing service available today can be extended to a continuous monitoring service that reviews processing and payments in real-time. It's the ultimate oversight tool and finds much more in savings than the service cost. But the best part is the reports it produces that put sponsors in charge of their medical and pharmacy claim payments in real-time. When the processing function is outsourced, it's often challenging to keep tabs on what's happening. The independence of an audit also produces unbiased reports and a clear snapshot of what's happening with payments.

If your past claim audits have been with the random sample method, it's time to step up to a 100-percent process with advanced software. You'll be impressed by how little of your time it requires; today, the firms work on their own once the setup is complete. All you do is provide a summary of your covered services and medications, and they're ready to go. It's why frequent auditing or continuous monitoring has grown in popularity so much in recent years. It's appealing to upper management who answer to boards or stockholders (or both). Having detailed reports about claim payments is essential for them.