The modern pharmaceutical industry, with billions in profits on the line, strongly advocates for its self-interests. The industry’s investment in research and development is cited as the reason for high costs, but profits are also built into the equation. An Rx audit is one defense against skyrocketing prices for self-funded healthcare plans. Companies routinely offer rebates and discounts to hold market share when medicines have competitors. They are marketing techniques that encourage plans to all drugs to their formularies. However, audits can help ensure the credits are correctly issued as promised.
Thanks to technology and some leading-edge firms, claims auditing has improved by leaps and bounds in the past 20 years. What used to involve random samples for regulatory compliance has morphed into a management tactic to enhance performance and contain costs. Auditors are your best bet if you’re in-house at an employer-sponsored plan and responsible for oversight of your outside claim administrator. They can electronically review thousands (or millions) of claims payments in hours using powerful software and proprietary systems. The reviews can check each one for dozens of data points.
As you’d expect, claim auditing firms differ, and the most effective ones specialize in the field. Their daily work reviewing claims gives them a unique perspective and expertise beyond what others offer. Most have also developed proprietary methods and have experience auditing most claim administrators – generally, large health carriers that provide the service. Many service agreements contain performance guarantees, but only an independent audit can verify whether they are met. If yes, the good work continues, and if not, the audit data can suggest systemic improvements.
Despite everyone’s best efforts, there can be surprises in claim processing. Audits later deconstruct what occurred and allow a clear-eyed post-mortem. The COVID-19 pandemic is an excellent example. New uses for expensive medications and other medical products were rushed onto the marketing on an emergency basis. It skipped the usual review, approval, and launch process, allowing more orderly action. In the aftermath, pleas were left trying to untangle potential overcharges or lax enforcement of formularies and other provisions. In many cases, it’s easy to understand why claims auditing matters.
Company Name- TFG Partners, LLC
Address- 437 Grant St #1020, Pittsburgh, PA 15219
Contact Number- (412)-281-2228
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