Keeping health plan payments on track with medical claim auditing oversight is an increasingly popular strategy – and for many good reasons. With nearly all claims paid by third parties today on behalf of large employer-funded plans, a practical oversight function is essential. Disputes between plan sponsors and their administrators recently have made news along with a spate of fiduciary breach class-action lawsuits. Accurate claim process is always a concern for plans to avoid overspending on errors and other irregularities. Claim administrators stay ahead of many issues, but few can be 100 percent.
The member service dimension of accurate medical claim payments is also crucial. Plans must treat members fairly and equitably and wisely spend money on their behalf. When claims are paid in error, some members are treated differently, and inequalities develop. Auditors with medical billing expertise can find errors and suggest systemic fixes to avoid future ones. It’s a natural follow-up to a claim audit and one that doesn’t add to the cost of the service. In fact, claim auditing is budget-friendly, and the recoverable overpayments it flags exceed the service’s price.
The most effective claim auditors take each plan’s provisions into careful consideration. Effective audits must be customized, and there is no such thing as a one-size-fits-all approach. Reviewing medical and pharmacy claims is also distinct from tax and financial auditing because it must consider health care billing. Every audit presents a unique set of requirements, and bringing the needed knowledge to the table is essential. It’s also crucial to stay current. New products enter the market each year, and prices go up (usually) and down (sometimes but less often). Keeping current with cost trends is essential for auditors.
Claim audits can also lead to constructive meetings between plan sponsors, customarily large employers, and their third-party administrators. Any conversation based on factual data is more productive than one based on hunches or opinions. If there are issues to be addressed and the data calmly points them out, there can be agreement on what needs to happen to bring improvement. Then, plans are better positioned to respond when costs and utilization spike, as occurred in the recent pandemic. When claim payments aren’t as tightly managed with oversight, it opens more possibilities for irregularities.
Company Name- TFG Partners, LLC
Address- 437 Grant St #1020, Pittsburgh, PA 15219
Contact Number:(412)-281-2228
