When a benefit plan sponsor partners with a new third-party administrator (TPA) or pharmacy benefit manager (PBM), it’s a period filled with optimism and high expectations. The promise is improved claim payment accuracy and more cost-effective management. However, the question remains: are those promises truly being fulfilled? This is where medical claims and PBM auditing services are essential. Company-funded medical and pharmacy plans are notoriously complex, and integrating them into a TPA or PBM’s system introduces even more challenges. That’s why an implementation audit is a crucial step.
An implementation audit is the most reliable way to verify that claim payments are accurate and align with plan provisions. Effective plans pay claims precisely, ensuring members are served properly while maintaining budget discipline. Both corporate and nonprofit employers face financial risk with self-funded plans, making auditing a prudent strategy. When selecting an auditor, insist on one who reviews 100% of claims rather than random sampling. Comprehensive auditing is the industry standard, providing the most accurate results and helping prevent costly errors from slipping through the cracks.
Industry experts recommend conducting an implementation audit about 90 days after the transition. At this point, there is enough payment activity to assess accuracy, but it’s still early enough to catch recurring issues before they escalate. Large plans with a high volume of daily claims face greater exposure, but plans of any size can experience significant errors. Common problems typically involve incorrect setup or incomplete integration of plan details within processing systems. Even the most diligent TPAs and PBMs can make mistakes, reinforcing the need for a full audit of all paid claims.
After the initial implementation audit, consider maintaining continuous audit software monitoring. Ongoing oversight can help prevent substantial errors from occurring. This proactive approach enables plan sponsors to address potential problems promptly and manage costs more effectively. While outsourcing claims processing can offer meaningful savings, those benefits only materialize when claims are handled with precision. Prioritizing implementation auditing at the outset—and maintaining vigilance afterward—ensures your plan remains on solid financial footing and delivers on its promises.
