It would be hard to think of a time when medical claim auditing services weren’t of significant importance. They help keep self-funded health plans on track and ensure that claim administrators do their work accurately. If you’re in-house at a plan sponsor conducting oversight, nothing compares to an independent auditor’s report on your claim payment accuracy. When mistakes are detected and flagged soon after they occur, it’s much easier to request corrections and reimbursement. Members with high deductible plans also benefit from accurate claim processing. It benefits all concerned.
Fiduciary best practices are essential to all medical plans to ensure they serve members well and avoid legal or regulatory scrutiny. Nothing replaces the ability to certify correct payments and uniform treatment of members according to plan provisions. When there are irregularities, your plan is open to many complications, which are easier to avoid with routine audits. It also demonstrates a good-faith effort to spend funds carefully and prevent waste. It is beneficial to plan sponsors for apparent reasons, but it also holds sway in other areas. Each year, costs and accountability standards increase for benefit plans.
The timing of claim audits can also figure into their value. You may schedule one shortly after the close of a plan year to give it a thorough review. Or, you might want an implementation audit three months after starting with a new claim administrator. Some plans also have their claims reviewed continuously with monthly reporting. It’s the optimal way to keep a handle on your cash outflows and the accuracy of your administrator. One thing that perennially drives the need for claim reviews is the complexity of medical billing. Untangling complicated claims to discover and flag errors requires unique expertise.
If you follow the history and development of claim auditing, you’ll see it’s a field known for continuous improvement. Firms that have pioneered advances such as 100 percent audits and vastly improved their proprietary software have led the way. The original days of random sample audits as the most effective claim review method are long gone. Today, when all claims are reviewed and checked against hundreds of data points, the audit accuracy is impressive. It also requires less staff time because the electronic review gets close to the finish line. Therefore, plans have much to gain.
Company Name- TFG Partners, LLC
Address- 437 Grant St #1020, Pittsburgh, PA 15219
Contact Number:(412)-281-2228
