Discussions

Over the past decade, the landscape of corporate and nonprofit employee benefit plan management has shifted significantly, particularly in how costs are managed. One standard recommendation from management consultants has been to outsource certain functions, such as benefit claim processing. A good first step is to claim administrator and PBM RFP consulting. When a third-party administrator (TPA) manages substantial fund outflows, meticulous oversight becomes essential. Errors and overpayments can occur frequently, so self-funded plans cannot afford to overlook them.

Most agreements between TPAs, PBMs, and self-funded medical or pharmacy benefit plans include performance guarantees, but the only way to ensure these are being met is through thorough auditing. Audits support management rather than foster an adversarial relationship among the parties involved. For private-sector employers that self-fund their medical plans, rising costs and budget overruns impact financial statements and quarterly earnings reports. These fluctuations can affect stock prices, making it vital for senior executives and board members to maintain accurate medical expense reporting.

The unexpected coronavirus pandemic presented a massive challenge, catching many self-funded plans unprepared and resulting in extraordinary costs. As managers and executives scrambled to assess where funds were directed during this chaotic time, the importance of rigorous auditing came to the forefront. Fortunately, today's advanced auditing software can handle the scrutiny required, checking every claim paid and providing swift, detailed reports. This technology is adept at identifying mistakes, detecting patterns of fraud and abuse, and recovering overpayments, especially in light of past exorbitant charges.

A vital component of effective self-funded plan management is accurate information. Additionally, exploring continuous claim monitoring services can be beneficial. Utilizing real-time software to track claim payments as they occur enables oversight that can significantly mitigate issues. Companies that have adopted this approach often find immediate benefits, as errors and overcharges are identified early on, preventing them from escalating into more significant problems. In today's dynamic healthcare environment, proactive auditing and monitoring are vital for effective financial management.