Digging In to Claim Audit Details

[tfgpartners]

Employers, both corporate and non-profit, who self-fund their health plans aim to furnish essential benefits to their workforce. However, the constant rise in prices makes diligent cost control a necessity. Conducting medical claim and PBM audits at least once a year is a sensible approach. As outsourcing claim payment to third-party administrators (TPAs) has become standard practice, the significance of comprehensive oversight has increased significantly. Notably, effective audits and monitoring often recover as much as four times their cost, showing the tangible financial benefits of robust auditing.

Recent advances in analytical software have changed the medical claim auditing process. The industry has moved away from random sampling, opting instead for complete 100-percent audits that deliver far greater accuracy. These advanced technological enhancements have not merely improved the speed and output of audits, but likewise minimized the need for human handling in repetitive tasks. As a plan sponsor, you benefit from more useful insights and save time compared to the older, less precise methods. When recurring errors are identified, you can proactively pursue systemic improvements.

When negotiating or renewing agreements with your TPA, it is essential to examine the contract details. Sometimes, carriers attempt to insert limitations into their agreements. For a self-funded medical plan, restricting claim processing oversight is rarely in your best interest. The only way to effectively manage your plan is by reviewing claim payments in detail. The more comprehensive your review process, the better your ability to spot issues and control costs. Even if your TPA offers performance guarantees, it is wise to independently verify their accuracy and protect your plan’s interests.

Independent auditors who specialize in medical claim reviews bring valuable expertise and work with all types of TPAs. Their experience makes certain that your plan benefits from an impartial, knowledgeable assessment right from the start. The more closely claim payment activity is examined, the more reliable and actionable your data becomes. Auditors can help you uncover overpayments, discover patterns of fraud or abuse, and provide recommendations for structural improvements. By giving precedence to audits, you improve the quality of your plan management and demonstrate strong stewardship.