Claim Audits: Health Plans' Best Oversight

TFG Partners
Published on Jan 19, 2024

Nothing produces factual data about a health plan's performance more accurately than a claim payment review. The valuable data explains why medical claims auditing continues to grow in importance as employer-funded health plans struggle to contain costs. When today's advanced systems electronically review a plan's claim payments, the reports produced give unmatched insight into all irregularities and point to improvements. It's a far cry from the random samples of yesteryear that never turn out the same way twice. It's helpful when you have consistent data and can compare year-to-year performance.

One of the chief reasons employer-funded health plans need claim auditors is because they outsource their claim administration. It means a third party is writing checks on the plan's behalf, and the sums of money are significant. When considering the trend toward fiduciary best practices, you can see how auditing fits in immediately. Self-reporting clauses are built into many processor agreements, along with accuracy guarantees. But are they being honored? Only an independent audit by a third-party firm can verify it – and work with only the plan sponsor's best interests in mind. It's a meaningful difference.

It's also common for employer-funded plans to switch third-party claim administrators and pharmacy benefit managers; implementation auditing is crucial in those cases. You can schedule an independent claim audit after 90 days to assess plan performance. If irregularities arise, there is time to make system improvements before they become million-dollar problems. Members are also better served when claims are paid correctly. When they aren't, inevitably, some members benefit while others lose out. Again, it's fiduciary best practice to have your plan performing optimally.

Seeing the opportunity, large audit and consulting firms are wading into the claim review industry. They have expertise, but can it match the specialist firms devoting themselves entirely to the field? You'll benefit the most when you have experienced auditors on your side checking based on years of experience in the area. Audit setup, ensuring your plan's unique provisions are considered, also plays a significant role in a claim review's value. Any firm that takes a cookie-cutter approach won't do as well as one that considers your needs uniquely. It's a simple fact of how the review and reports will work.

Company Name- TFG Partners, LLC

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

Contact Number:(412)-281-2228