Corporate and nonprofit organizations that self-fund their employee health and pharmacy benefit plans are increasingly turning to advanced medical claim auditing for oversight. Most organizations now outsource claim administration to third-party administrators (TPAs) and pharmacy benefit managers (PBMs). With the continuous rise in costs, it’s essential to ensure that accuracy...
In today's landscape, many large self-funded benefit plans rely heavily on outsourcing for their medical and Rx claims administration. But how were things set up initially? That's where medical and PBM RFP consulting is valuable. Setting up favorable agreements with third-party administrators (TPAs) and pharmacy benefit managers (PBMs) is essential. Given that medical and Rx claims tend to be...
Running a medical and Rx audit to review paid claims has evolved. Initially, the process relied on random samples, which limited the accuracy. However, advancements in technology have enabled the capability to audit every payment, resulting in higher accuracy rates in identifying discrepancies. Audit firms that tailor their services to the details of a plan's covered services can provide the...
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