All health plans, especially those self-funded by large employers, try to find ways to deliver excellent care at the lowest possible cost – but it’s never easy. If you’re in-house at an employer-sponsored health plan, consider medical claim auditing services to help with cost management. You likely have an outside processor handling claim payments, and oversight of their work can be insightful. Nothing is more concrete than factual data based on claim payments. It is the most precise picture of how members use your plan and what it pays for services – and consider similar auditing vigilance for your Rx claims.
You can audit frequently or monitor your claim payments in real-time to keep close tabs on your costs and administrators’ accuracy. If you’re interviewing audit firms, ask about their process for setup. It boosts accuracy when set up thoroughly and mindful of your plan’s provisions. The less general and more specific the claims review is, the more you’ll find out. Claims auditors who limit their work to the field also have proprietary systems and methods that may exceed what a generalist auditor uses. Understanding the complexities of medical billing in coding helps produce greater accuracy.
What’s also vital about claim audit firms is their independence. It is reassuring to know they are working only for you and have your plan’s best interests at heart. As you develop relationships with a firm over time, they learn more about your plan and recall past problem areas. They are keeping the spotlight on where mistakes have occurred in the past, which is often helpful. Knowing which providers are prone to overcharges, incorrect coding, etc., is also in your best interests. Every claim paid is a complex endeavor, and audit firms that can untangle the details and give you a clear picture are more valuable in the long run.
As you’re negotiating agreements with claims administrators, you can build in audit verification requirements that occur routinely. It’s the way to be assured that contracts are honored and accuracy results align with what’s reported. If you’ve only had your plan audited periodically to comply with regulatory requirements, consider making claim reviews part of your management and oversight system for the benefits they can bring. It’s also helpful to have built-in audits when an extraordinary event like the coronavirus pandemic occurs. Plans with agreements were in stronger positions with data and facts.
Company Name- TFG Partners, LLC
Address- 437 Grant St #1020, Pittsburgh, PA 15219
Contact Number:(412)-281-2228
