Let Claim Auditing Help You Start Right

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Company Medical and Benefit Claims Auditing | TFG Partners

Large-employer-funded benefit plans overwhelmingly outsource their claims administration to third-party administrators, especially for health coverage. The advantages are the processor's expertise in claim payments and their negotiated rates with providers. But oversight is necessary, and it's why medical claim auditing services are in such great demand today. Their services are especially helpful as plans switch to new third-party administrators or pharmacy benefit managers for claim payments. Even with accuracy and performance guarantees that hit targets, doublechecking the payments is a wise idea.

When you schedule an implementation audit 90 days after a new TPA and PBM begin, there's enough claim payment experience to get a clear picture. The goal is to catch errors before they add up to million-dollar problems. It also ensures all members are treated equally with uniform payments for their services. You can also make corrections with any providers that are overbilling or substituting services or medicines incorrectly – think dispensing name-brands medicines rather than the specified generics. Excellent claim administration is the sum of many details, handled each time correctly.

The advances in software and systems have changed the game with all claims auditing. Audit firms specializing in the field have sharpened their expertise through the years and today work with an unrivaled level of accuracy. They have systems expertise with well-known processors and can run audit software on their systems effectively. Auditing benefits helps everyone in the equation, from the plan sponsor to the processor, provider, and member. Being timely with it also simplifies the correction and overpayment recovery processes. Each runs more smoothly in real-time than months in arrears.

Once you've run an implementation audit and have factual data in your hand, it leads to meetings and conversations about system improvements. Accurate data isn't debatable, so everyone works from the same information toward long-term solutions. It adds efficiency and the potential for long-term cost savings not achievable without close oversight. Some audit firms also offer continuous monitoring services that keep a real-time eye on claim payments. When you receive readable weekly or monthly reports about errors and overpayments, it facilitates closer plan management that's more effective.

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