Guest
Guest
Jun 28, 2026
11:23 PM
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The pandemic served as an important wake-up call for health and pharmacy benefit plan sponsors, showing how rapidly costs can escalate. It placed health plan auditing services—and pharmacy claim audits—in the spotlight as never before. However, the opportunities for error detection and recovery of funds vary considerably between the two types of plans. As a result, selecting an audit firm with proven expertise in both medical and Rx is essential, even including PBM RFP consulting. If you are responsible for managing a plan, it is important to understand what to look for when interviewing auditors.
A primary focus in medical plan claim audits is laboratory testing and imaging, which can rapidly accumulate high costs and are prone to frequent billing errors. Overlapping or unnecessary tests must be identified and flagged. Third-party administrators (TPAs) often pledge to monitor these issues, but mistakes can easily go unnoticed. The same scrutiny applies to physician fees, which may vary greatly for identical services. Consistent vigilance is required to ensure claim payments remain accurate, and any charges that exceed reasonable and customary benchmarks should be thoroughly examined.
For pharmacy claim payments, auditors ensure that only medications listed on the formulary are reimbursed. Name-brand drugs are often prescribed or dispensed when lower-cost generics are available, resulting in unnecessary expenses. A plan’s generic policy is only as effective as its oversight, making it vital to verify what was actually covered and paid for. Auditors should also review usage patterns, such as monthly maximums, refill frequencies, and related factors. Additionally, drug manufacturers frequently offer rebates, and an audit can confirm whether these rebates are credited.
Today, independent auditing firms specializing in both medical and pharmacy claims increasingly use a 100-percent review method, which delivers unmatched accuracy. This thorough approach results in recoveries that far exceed the cost of the audit service—sometimes three to four times as much. Apart from financial benefits, comprehensive audits help improve member service by making sure that rules are applied consistently and all plan members are treated fairly. Forward-thinking organizations conduct audits at least annually, and many deploy audit software for ongoing, real-time oversight.
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