While recovering overpayments is often seen as the primary benefit of health plan claim reviews and pharmacy benefit manager audits, the true long-term value comes from identifying errors that reveal system setup issues. These types of errors can lead to repeated, large-scale mistakes that, over time, result in losses and require effort to correct and recover. Implementation audits offer more than financial recovery—they enhance member service and help ensure that claims are managed fairly and consistently. Resolving errors through audits leads to lasting improvements and cost-effectiveness.

Whenever your health plan transitions to a new third-party administrator (TPA) for medical claims or a new pharmacy benefit manager (PBM), conducting an implementation audit within 90 days is a smart move. This procedure guarantees that your plan is set up correctly in the new administrator’s system. If your contract includes performance guarantees, an independent audit verifies whether these standards are being met. Top-performing TPAs and PBMs often appreciate audits as validation of their quality, while a reluctance to undergo auditing may show potential basic issues.

Most TPAs and PBMs manage multiple plans and rely on standardized setups. However, every plan includes special features. Implementation audits help confirm the accuracy of your plan’s configuration and guarantee a smooth transition to the new vendor. Auditing early and regularly is recommended, as high-quality claim audits uncover savings that far exceed the cost of the service—sometimes up to four times as much. For plan managers used to random sample audits, it’s revealing to observe what an audit that reviews 100 percent of claims can reveal, offering much greater accuracy and insight.

While TPAs and PBMs may promise accuracy and value, without independent oversight, you have to rely on their guarantees. Although most vendors aim to fulfill their contracts, only a third-party review can truly confirm performance. After a thorough audit, it’s beneficial to implement a continuous monitoring service. Ongoing monthly reports can highlight errors as they occur and alert you to trends in claims processing and payments. This active approach helps you control costs and preserve high standards of member service in real time. Otherwise, you might not find issues until the next planned audit.