Implementation Audit FAQ’s

The basics.

A healthcare claims Implementation Audit, also known as a plan setup audit, implementation review, pre-implementation, or post-implementation audit, is a test of how your medical or prescription drug plan is configured by a third-party administrator (TPA) or pharmacy benefit manager (PBM).

This audit uses tailored test scenarios to verify that claims processing systems are set up correctly to administer your health plan benefits. Implementation audits are typically performed before go-live, but can also be conducted after go-live to catch and correct setup issues early in the process.

By identifying and correcting setup errors early, an implementation audit helps ensure accurate claims administration from the beginning. It is a proactive quality control measure designed to build trust, avoid costly mistakes, and lay the groundwork for a successful ongoing relationship with your TPA or PBM.

All healthcare plan sponsors should consider an implementation audit when undergoing key changes that could impact claims accuracy or benefit administration. These audits are especially important for plans that are:

• Making benefit changes that impact the way a TPA or PBM processes or pays claims

• Changing to a new TPA or PBM

• Moving to a self-insured model

In these scenarios, a healthcare claims Implementation Audit ensures that systems are properly configured before or after go-live. This proactive review helps identify setup errors, avoid costly claims processing issues, and ensure a smooth transition for members.

HELPFUL TIP: Be sure to ask the new TPA or PBM for implementation credits to help cover the cost of the audit.

BMI offers implementation audit testing for medical and pharmacy benefit plans.

During a healthcare plan Implementation Audit, several critical areas are tested to verify that the health plan has been configured accurately and functions as intended. These audits evaluate whether the claims processing system aligns with the plan’s specific design, benefits structure, and administrative rules. Key areas of testing typically include:

• Deductibles

• Coinsurance

• Copays

• Exclusions

• Out of Pocket

If a claim processed during the audit produces an unexpected result, it indicates an error that would have occurred in the live environment. Identifying and correcting these errors before or after go-live helps ensure accurate claims payment, regulatory compliance, and member satisfaction.

Read about real-life implementation audit outcomes here.

The best time to conduct an implementation audit is as close to the effective date as possible. There are two different timing options to choose from:

• A pre-implementation audit is ideally conducted 3-4 months before the effective date, in order to complete the audit before any live claims are processed.

• A post-implementation audit is conducted after the effective date and when live claims have started processing.

Both pre- and post-implementation audits are designed to detect setup errors, allowing for processes to be corrected as early as possible.

Yes. An Implementation Audit can be done even if the plan is already live. This is referred to as a post-implementation audit, which is designed to detect setup errors and allow processes to be corrected early in the plan year.

A healthcare plan implementation audit takes an average of 3-4 months from start to finish. For plan sponsors or broker consultants, the process requires minimal effort, approximately 1-2 hours total.

Healthcare plan implementation testing costs are dependent on the number of plans being tested, and the type of plan(s) that are included in the testing. The best way to determine the cost of healthcare implementation testing is to request a quote from the BMI team.

Don’t forget to ask for implementation credits! Oftentimes, the new TPA or PBM will be willing to include implementation credits in the agreement to help cover the cost of the audit

The benefits.

It is important to conduct a healthcare plan implementation audit because errors can occur, and standard TPA/PBM processes and setup may unintentionally override custom plan designs if not thoroughly tested. BMI adopts an objective, member-focused approach by using tailored testing scenarios to identify setup errors and resolve them before claims are processed. This proactive step ensures a seamless start with the TPA/PBM, building trust and setting the foundation for success.

Accuracy from the start. Healthcare plan implementation audits give plan sponsors the confidence that benefits are aligned with the Summary Plan Description (SPD). With accurate processing from the start, plan sponsors can:

• Enhance member satisfaction by preventing coverage and billing issues

• Strengthen fiduciary oversight through proactive error detection and correction

• Avoid wasteful spending by addressing mistakes before they affect claims

See examples of implementation audit outcomes here.

Implementation Audits impact healthcare costs by identifying setup and process errors early, helping to prevent future wasteful spending and non-compliance with federal regulations.  

Under ERISA, fiduciaries are required to act prudently and solely in the interest of plan participants. An implementation audit supports fiduciary duty by proactively verifying that systems are set up to pay claims accurately, according to plan terms and contractual agreements. Implementation audits provide an opportunity for plan sponsors to document supervision, identify systemic errors, and show that plan assets are being managed responsibly.

Types of audits.

BMI Audit Services offers two types of implementation audits:

BMI recommends a pre-implementation audit to ensure the plan is set up correctly before any claims are processed.

This is important because it:

• Avoids frustrations felt by members and employees due to processing errors that directly impact them

• Saves time by eliminating the need to review all impacted claims when the setup is incorrect

• Protects plan dollars from being spent incorrectly

Many administrators have the ability to conduct internal reviews of their systems, but these assessments may be influenced by internal processes that do not fully align with the plan's design. An independent auditing firm offers an objective perspective, evaluating the setup with members and employers in mind to identify errors before claims are processed.

How it’s done.

BMI’s Implementation Audits follow a structured, multi-step process to deliver accurate results and actionable insights:

1. Preliminary Steps
   We begin with a kickoff call to align on audit goals, timeline, and responsibilities. The client shares plan documentation and sends the audit notification to the TPA and/or PBM.

2. Review of Documentation
   BMI will acquire and review the TPA’s and/or PBM’s documentation detailing their implementation processes, procedures, and system setup to determine what benefits need to be tested.

3. Selections
   The BMI team works together with the TPA and/or PBM to create a sample of claims. Claims are tested against various categories, including:

   • Limitations

   • Accumulators

   • Copay levels and application

   • Out-of-pocket rules

   • Exclusions

4. Reporting & Recommendations
   The report provides key findings from the audit, including an analysis of inconsistencies between the plan language and the Administrator or PBM’s plan setup. BMI offers expert recommendations to resolve and remediate identified discrepancies, ensuring alignment with the intended benefit plan design.

To start an Implementation Audit, BMI will need the Summary of Benefits and Coverage document (SBCs), prior SPDs, as well as a summary of any plan modifications that were made.

BMI can complete an Implementation Audit without using live claims data by creating test claims based on the plan’s unique criteria to simulate real-life scenarios. This allows BMI’s experts to verify that the system is configured correctly and that key processes are functioning as intended.

After completing a healthcare claims implementation audit, BMI delivers a detailed report and hosts a wrap-up session to discuss the findings and provide guidance on any next steps and corrections that may need to be taken with the plan administrator.

To ensure claims processing remains consistent with the plan, and members are receiving benefits they were promised, BMI recommends conducting a comprehensive Healthcare Claims Audit after the first full plan year.

For more information about BMI’s Healthcare Claims Audits, check out our frequently asked questions.