Claim Audits are Better, Here's Why

TFG Partners
Published on Oct 12, 2023

The never-ending drive to improve technology is now getting so far with artificial intelligence that it's causing alarm. But advances in other areas, like claim reviews for a healthcare audit, benefit significantly from advanced technology. Reviewing medical and pharmacy claims has become a big business as large employers who self-fund their plans seek help. With third-party administrators (TPSs) and pharmacy benefit managers (PBMs) dolling out billions of dollars for other companies, oversight is vital. Today's electronic claim reviews are more powerful than ever and can flag even tint irregularities.


Good plan management requires auditing frequently to find systemic errors that cause overpayments or a group of mistakes. However, there is increasing viability in flagging mistakes individually and allowing plans to request repayment. Today's software and systems have advanced capabilities and work even faster than previous, less precise versions. The claim auditing industry is led by a group of specialist firms concentrating all their efforts in this area. Most have medical billing and claim payment expertise, allowing them to zero in on the problem areas and spot even small mistakes reliably.


When you look at the science of claims auditing, the other dimension is system setup. Your plan has nuances, and its provisions are unique in some areas. Auditors who take the time to consider those carefully and adapt their systems produce better results. Their reports are richer in detail and report trends that you can compare with your TPA and PBM's self-reporting. When both sides agree, you can rely on the data; if there is disagreement, you can examine things further. Medical and pharmacy claims are complex and become more complex each year; you must also watch new services.


Plan for an implementation audit if you're about to switch to a new TPA or PBM. They're typically scheduled after 90 days to double-check claim payment accuracy. Many plan sponsors and their representatives are surprised (and impressed) by how much an independent review will turn up. Undoubtedly, error rates are impressively low, but even minor errors can amount to a lot for more extensive plans. Regardless of your plan's size, auditing is worthwhile and helps improve performance and contain costs. There are member service and fairness gains when all claims are paid uniformly. 


Company Name- TFG Partners, LLC


Address- 437 Grant St #1020, Pittsburgh, PA 15219


Contact Number:(412)-281-2228