When choosing among medical claim auditors, hold out for a firm with deep expertise in the field. Given the intricacy of medical claims, there are many opportunities for errors, even when processors have sophisticated systems. When an auditor knows medical billing and understands all its details, you’ll stand a better chance of finding every mistake. There are many ways providers can increase medical costs, and plan provisions are designed to prevent it. But are they being held to the highest standards, or are claims being paid for improper services? An audit helps you double-check.
The best way to make a claim audit most beneficial is to customize it. Anything close to a “one-size-fits-all” approach will guarantee things will be overlooked and opportunities missed. When employers sponsor health and prescription plans, they are carefully designed to deliver needed care at the lowest possible prices. As large health plans process claims, they bring employer plans onto their platforms. There can be cost savings on many levels, but some things may be overlooked even when error rates are low—given the cost of medical services and medicines, checking details matters.
When interviewing claim audit firms, also inquire about their experience in medical billing. When you can find a company whose people have health plan experience and knowledge of how claims are paid, they know where to look in an audit. Also ask how sophisticated their software tools are, how many error detection algorithms they use, whether they custom program all your unique plan design into the system, what the auditors level and length of experience is. This avoids cookie cutter, superficial audits that add no plan improvement value.
Ask how they use the latest available transparent data, results of the Consolidated Appropriations Act (CAA), other evolving national and state level pharmacy legislation.Learning where to look and understanding how each processor works also jump-starts the process and leads to more accurate outcomes. Using the same firm year to year also allows you to compare reports from different periods. Data-driven oversight is one of the most effective ways to ensure plans are managed optimally. It helps members and manages costs over time.
Pre-audit meetings also present opportunities you can maximize. In addition to asking questions about current and past experiences, you can focus the work on specific plan provisions. Every health plan is unique and contains opportunities for savings. If your processor missed any detail during system setup, an audit can find them and help make updates or corrections. The closer your processors’ system follows your plan provisions, the more accurately claims will be paid. It also keeps you more in control because payments are made according to the covered items you have laid out precisely.
Company Name- TFG Partners, LLC
Address- 437 Grant St #1020, Pittsburgh, PA 15219
Contact Number:(412)-281-2228
