Each year presents a fresh set of dilemmas about rising costs for employer-sponsored health and pharmacy plans. Many plan sponsors routinely conduct a medical and Rx audit to monitor their expenses and payments. Outsourcing claim administrators to large health plans and pharmacy benefit managers is routine. Their claim processing systems are accurate and can cost-effectively handle a high claim volume. Many deserve credit for the improvements they have driven throughout the process. But no system is infallible, and mistakes are routinely made. Auditors find them and report each one.

Every pharmacy plan decides which new and expensive medicines to include, and discounts and rebates are often promised. If you accept a brand-name medication for your formulary, are you sure all credits are being applied properly? An auditor can help answer the question, and with the data, you can follow up on any shortfalls. It's better than trusting only your pharmacy benefit manager to be on the lookout. There have also been cases where PBMs have overcharged for medicines or kept discounts due to their client companies. It's a multi-dimensional process for auditors to review. 

Keeping track of price changes in real-time is also crucial. For example, if a frequently prescribed medication goes off patent mid-year, is the switch to the lower-priced generic immediate? Details like these matter when cash is on the line, and an independent claim audit firm has only your plan and the company's best interests at heart. On the medical side, disagreements end up in court as plans accuse their claims administrators of overcharging them. The pharmacy world operates under different guardrails, but the general point is the same. Oversight of all claim payments helps.

Utilization changes such as those brought by the coronavirus pandemic put plans under a particular financial strain. When audit systems are in place, questions can be answered quickly and issues resolved expeditiously. No one planned for the pandemic, but employer-sponsored plans that were well-managed fared better. The systems they already had in place allowed more effective management through tough financial times. Audits conducted toward the end of the pandemic also helped unwind high costs and challenged questionable payments. No one emerged unscathed, but some plans did better than others.