Post-Implementation Audits: How Medical & Prescription Reviews Protect Plan Sponsors
When health plans launch new designs or adjust benefit structures, accuracy isn’t guaranteed on day one. Implementation audits are the critical “second check” that ensures benefits align with the Summary Plan Description (SPD), Summary of Benefits and Coverage (SBC), and employer intent.
For one of our long-term clients, BMI Audit Services conducted post-implementation audits for both medical and prescription claims, to ensure that benefits were applied correctly and to identify areas that required clarification. This complete approach taken by the plan sponsor during implementation of a new plan provided peace of mind, stronger fiduciary oversight, and a better start towards long-term cost control.
Business Situation + Client Profile
The client, a multi-plan employer offering PPO, EPO, and HSA options, engaged BMI Audit Services after implementing both medical and prescription plan changes. With thousands of employees relying on these plans, the organization recognized its fiduciary responsibility to verify benefit accuracy, confirm exclusions, and ensure member cost-sharing aligned with documented plan rules.
Objectives
The client’s primary objectives included:
Validating medical and prescription plan designs against the SPD and SBC
Confirming correct set-up of deductibles, copays, and out-of-pocket maximums
Ensuring exclusions, limitations, and prior authorization requirements were consistently applied
Detecting discrepancies early to avoid member disruption, compliance issues, and unnecessary costs
The Solution
BMI deployed its post-implementation audit methodology across both medical and prescription plans:
Medical Implementation Audit: Over 800 test scenarios reviewed across PPO, HSA, and EPO plans, evaluating deductibles, OOP maximums, exclusions, and limitations (e.g., therapies, mental health, maternity, vision).
Prescription Implementation Audit: 300 scenarios tested across the client’s prescription benefit plans, incorporating ACA preventive drugs, step therapy, tiered copays, refill limitations, and exclusions.
Testing was performed directly against the administrator’s and pharmacy benefit manager’s adjudication systems, allowing real-time validation of how claims processed against the plan rules.
Audit Findings
Medical Implementation Audit:
800+ scenarios tested across PPO, HSA, and EPO plans.
Most benefits were configured correctly.
3 key areas required clarification of plan intent:
Vision exam limitations
Cataract surgery coverage
Inpatient maternity vs. outpatient benefits
These discrepancies highlighted the need for updated SPD/SBC language to prevent member confusion.
1 notable compliance issue: The HSA plan’s deductible was non-embedded while the out-of-pocket maximum was embedded, conflicting with SBC language and requiring correction.
Prescription Implementation Audit:
300 scenarios tested across the client’s prescription benefit plans.
Nearly all scenarios, including copay tiers, supply limits, and prior authorizations, were programmed to be processed correctly.
1 area required a second round of testing, which the pharmacy benefit manager promptly corrected, confirming accurate application of all benefits.
Recommendations
Clarify Plan Language: Update SPD and SBC documents where language conflicted with actual plan adjudication, to ensure member expectations align with real claims outcomes.
Address Plan Intent Decisions: Where discrepancies exist (e.g., cataract surgeries, vision exams, inpatient maternity), the plan sponsor must determine its intent and document updates accordingly.
Maintain Ongoing Validation: Regular healthcare claims audits for both medical and prescription claims should be part of fiduciary best practices to ensure continued accuracy, compliance, and member satisfaction.
Conclusion
For this client, the complete post-implementation medical and prescription claims audits confirmed that their administrator and pharmacy benefit manager had largely configured benefits correctly, while also uncovering areas where the plan documentation and adjudication required closer alignment.
By proactively auditing after implementation, plan sponsors demonstrate fiduciary due diligence, protect member trust, and avoid costly errors.
Whether it’s validating dependent eligibility, medical claims, or pharmacy benefits, audits safeguard the integrity of employee benefit plans and provide measurable value to both employers and plan participants.