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Kumaran Farms Group

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Dual Pharmacy and Medical Claims Audits


In the aftermath of the COVID-19 pandemic, significant discussion has been about auditing medical and pharmacy claims. Healthcare auditing companies were called to review payments and provide data and insight. The surge in costs related to COVID-19 led to unprecedented financial implications for some plans, with new tests and services entering the market at varying costs. The billed prices for similar items could differ significantly depending on where plan members sought services. Audits have played a crucial role in unraveling these complexities, providing helpful insight.


Specialist claims auditing firms equipped with unique expertise and proprietary software have been instrumental in conducting comprehensive reviews. They help plan sponsors prepare for similar future events, particularly for self-funded plans from large employers. Their services often involve scrutinizing 100% of claim payments against numerous details. Subsequent analysis has revealed staggering charges and cost trends in various areas while flagging mistakes and irregularities. Sponsors receive detailed reports on their plan's performance, enabling in-house staff to run more effective oversight.


Medical claims audits focus on specific checkpoints, including reviewing thousands of claims to identify excessive doctor fees and analyze lab test charges against National Correct Coding standards. Payments exceeding standard rates and redundant test pairs are also scrutinized. High-quality claim auditors are recognized for providing thorough and actionable reports. Pharmacy claim audits involve numerous checkpoints and require each claim to be checked against the formulary to ensure compliance with name brands and generics. Each type of claim auditing requires particular expertise.


Ensuring that generics are dispensed when available and monitoring quantity limits for refills are crucial aspects of pharmacy claim auditing. Identifying and addressing errors in these areas is essential to avoid long-term financial implications. There's also an effect on PBM's work quality when they know plan sponsors are actively running oversight. Discounts and rebates also require work, and ensuring they're doing it so your plan qualifies is crucial. When thousands of medications are dispensed daily, even the most effective systems allow some things to fall through the cracks, costing you.


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