Year in and year out, medical claim auditors provide substantial value to the employer-funded health plans that are their primary clients. Claim reviews improve budgets because they nearly always lead to recoverable overpayments worth two to four times the price of the audit. There are also long-term benefits because their work often leads to system fixes that prevent future errors, meaning their value is even greater than what's recovered in the short term. Medical and pharmacy benefit plan sponsors have much to gain by auditing routinely or monitoring claim payments continuously during the year.
It may come as a surprise that claim audits began as a regulatory and compliance function, given their importance in financial management today. They started as random samples and showed broad trends but fewer details. With today's powerful software and systems, auditors screen every claim paid and produce factual reports with impressive detail. As a result, it's easy to see why more frequent auditing has become the norm when large employers, corporate and nonprofit, self-fund their benefit plans. Each category requires different expertise, but all provide opportunities to recover overpayments.
Recently, a large employer has taken its third-party claim processor to court in some high-profile cases, alleging overpayments and overcharges. The items mentioned in the complaint are likely what audits pick up when claims are reviewed. There's no doubt that medical billing is complex, and paying claims following a plan's provisions takes careful work. Even with ultra-low error rates, there is an opportunity for meaningful recoveries when an audit picks up mistakes. Sometimes, errors are buried deep within the complexity of a complicated claim, and finding them takes experience and expertise.
For anyone in the industry long enough to recall the days of random sample audits, it's an eye-opener to see a 100 percent review. Much more is revealed when every claim paid is double-checked to impressive detail. Today, it is possible to make recoveries for individual overpayments rather than only those that were part of a larger error pattern. It also makes a case for auditing routinely and preventing million-dollar problems from occurring. During periods of higher use and rapid change, such as the coronavirus pandemic, it's wise to review claims to double-check them soon after they are paid.
Company Name: TFG Partners, LLC
Contact Number: 412-281-2228
Address: 437 Grant St #1020, Pittsburgh, PA 15219
