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A Way to Manage Health Plan Costs
A Way to Manage Health Plan Costs
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TFG Partners
1 post
Dec 24, 2025
1:49 AM
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Large employers that offer self-funded medical and pharmacy benefit plans face a unique situation when they outsource claims processing. Essentially, they’re trusting a third-party company to spend their money accurately and fairly when paying out claims. This setup creates an inherent need for oversight, which is where a medical claim and PBM audit come in. While most claim administrators and pharmacy benefit managers (PBMs) today do an impressive job—keeping error rates very low—it’s still crucial for sponsors to make sure overcharges or mistakes are routinely identified and corrected.
With healthcare costs rising year after year—and the added challenges highlighted by the coronavirus pandemic—managing expenses requires a multifaceted approach. Accurate claims payments don’t just affect the bottom line; they’re also a matter of fairness for plan members, ensuring everyone receives equal treatment. Sticking to your plan’s provisions helps improve performance, control costs, and provide better service. However, without regular audits and payment reviews, sponsors working with outside processors often rely solely on the reports those processors provide.
Choosing the right claims auditor and building a relationship can deliver significant benefits. Over time, auditors become familiar with the specifics of your plan and provide consistent, reliable reports. This makes it easier to compare different years or periods, spot trends in costs, error rates, and other claim payment details. If you’re switching to a new third-party administrator or pharmacy benefit manager, it’s smart to do an implementation audit. Giving the new partner time to set up your plan correctly is crucial for ensuring claims are paid accurately. It’s a good idea to review their work after a few months.
Continuous claim reviews are a newer, fast-growing approach that keeps a constant eye on payments. Modern audit software runs in the background and provides monthly reports on any discrepancies or trends it finds. Ongoing oversight gives employer health plans leverage and helps keep processors accountable. The cost is usually far less than the amount recovered from catching errors. By staying on top of claim processing and payments, plans can avoid issues that might otherwise require costly fixes later. It’s a proactive, effective way to keep costs in check and maintain smooth operations.
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Dec 24, 2025
2:05 AM
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