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Many large employers need to ensure the accuracy of their health plans' claims processing, and medical and Rx claim reviews are a smart strategy when working with a healthcare auditing company. Prescription medications should be dispensed per your plan's formulary, and any promised discounts and rebates must be applied. But how can you be sure these processes are being followed? The best way to confirm this is by having professionals audit your plan's payments. The areas to investigate in pharmacy audits differ from those in medical claim reviews, so it's crucial to have expert support in this field.

The initial examination of your pharmacy benefit payments may reveal cost-saving opportunities. An increasing number of health plans are now continuously monitoring their claim payments. This practice is becoming a favored audit service due to its benefits. One significant advantage is the availability of monthly reports. The real-time nature of frequent reporting enables you to track your payments closely. When any inconsistencies arise, you can promptly address them with your pharmacy benefits manager, maintaining oversight that encourages optimal performance.

If there are promises of discounts and rebates, auditors can ensure these are honored. If your audits reveal considerable cost-saving opportunities, which can often cover the audit costs multiple times, you might consider a continuous claims monitoring approach. With access to real-time data, you'll be informed about payments as they are made and be quickly alerted to any irregularities. In today's data-centric environment, maintaining accurate expense tracking is essential. If costs deviate from what was expected, you'll have an independent analysis that sheds light on its reasons.

While most are diligent and maintain low error rates, the goal is to achieve zero mistakes. Collaborating with the same audit firm over several years allows for consistent reporting, facilitating comparisons of your data. It enables you to manage your prescription benefits program while gaining insights into claim processing efficiency. Modern audits leverage advanced software that uncovers numerous details once lost in random sampling, providing a review of each claim and answering any specific queries you may have based on your experiences. Each plan presents unique areas that require careful monitoring.