The stakes are high in medical claim processing; sometimes disagreements come into the open, as evidenced by a pending lawsuit. In it, a sizeable employer-funded plan accuses its' third-party administrator of paying excessive charges. A healthcare audit likely revealed some findings that led to the lawsuit. Auditing medical and pharmacy claims is essential to oversight for any self-funded plan. Even when the working relationship is not strained with a claim administrator, confirming the accuracy of their work is necessary. Often, auditors also can make suggestions about plan performance.
Getting it right with claim payments is a multi-faceted endeavor. Medical billing is complex, and coordinating services among providers can be challenging. When processors pick up on errors, they are doing their jobs optimally – and if not, auditors can pick up the mistakes and report them for future performance improvements. In some cases, errors may be recoverable overpayments, and when 100 percent of claims are reviewed, you can go after everyone who is flagged. Audits today are more accurate than previous ones that worked with random samples and human review.
As auditors will tell you, properly setting up their electronic systems for each plan is essential because it guarantees accuracy. Your plan has unique provisions, and when they are loaded correctly, every detail is scrutinized. Each claim has dozens of data points that can be checked. Prescription plan auditing is about the formulary, generics when available, discounts, and rebates. It's a detail-oriented process, and claim administrators make performance guarantees. Oversight helps ensure they are met, and comparing an independent auditor's report with their self-reporting is enlightening.
Two things have brought leaps ahead in claim auditing. The first is specialist firms that have developed deep expertise – most have executives with health plan experience. The second is technological advances that have made software more intuitive and intelligent. It's almost as though a human reviewed every claim, except doing it electronically covers thousands in minimal time. The efficiency is impressive and has driven down the price for the service as the results have improved. Plans always profit from audits, and recovering more than four times the audit price is increasingly common.
Company Name- TFG Partners, LLC
Address- 437 Grant St #1020, Pittsburgh, PA 15219
Contact Number- (412)-281-2228
