Claim Auditing is a Health Plan's Best Defense

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Company Medical and Benefit Claims Auditing | TFG Partners

By now, nearly all medical plan sponsors have concluded that health plan auditing services can save them money and improve their member service. Therefore it's logical to accept that continuous monitoring on the same audit software has the same potential. With claims processing nearly always outsourced these days, the oversight of an audit is a plan's best defense against costly errors and overpayments. TPAs and PBMs commonly make performance guarantees but relying on them to self-report without an independent review carry obvious risks -- let a claim auditor double-check. 

What's changed the game in terms of claim auditing accuracy is the 100-percent method made possible by technological advances. Software improvements that allow quick review of all claims against hundreds (if not thousands) of checkpoints produce reports and data of unmatched accuracy. They become helpful management tools enabling in-house staff to oversee claim administrators more effectively than ever before. You can check to see if performance guarantees are being met and be informed about trends in expenses and other factors when they are just beginning and easy to address.

Frequently audited or continuously monitored medical plans reported better management outcomes during the coronavirus pandemic. Given the significant effect spikes in claim costs can have on balance sheets, it's wise to keep tabs on expenses in real-time. It's what you have with continuous monitoring service. It runs audit software in the background at all times. You'll receive monthly reports, and the value of the mistakes it flags exceeds the cost for the service – so it's budget-friendly. Upper management on the line to explain costs to financial analysts and others appreciate the data you'll have.

It's also crucial to find a claim audit firm that is fully independent and specializes in the field. They have proprietary software and methods to do the highest quality job. Auditing is only as good as the data it generates, and you want to have the best. If you've only been auditing to meet regulatory requirements, consider checking your medical and pharmacy claims more often, at least annually. Sponsors of the best-managed plans have embraced audits as their most effective means of management and oversight. When you go without one for too long, mistakes and overpayments can pile up and be hard to recover.


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