Employer-Funded Health Plans Need Claim Audits


TFG Partners is a healthcare claims audit and monitoring firm that has been leading the industry for nearly 30 years.

There are well-established and financially sound reasons large employers sponsor medical and prescription plans for their employees. But the cost exposures are significant and careful oversight is necessary. Medical claim audits have become especially important as claim processing has been moved out of house to third-party administrators and pharmacy benefit managers. While most are large companies with well-established systems, they easily can miss some of a plan's unique features. No one does their best without independent verification, and plans and members have much at stake financially.

 

The 100-percent audit method that has replaced random sample checking has revolutionized the industry. It has ushered in a new era of accuracy, and when each claim is reviewed electronically and with expert human oversight, the results are impressive. Auditing today picks up emerging trends that will drive cost increases in their infancy. Many times, this information allows sponsors to intervene with negotiations and outreach. It's incredibly more effective than working after-the-fact trying to recover funds paid long ago. It puts the plan sponsor's staff in better negotiating positions.

 

Not enough can be said about the value of independent, specialist claim auditing firms. They have deep experience in the field and work on similar audits every day. It allows them to offer an unmatched level of efficiency and specialization. Their independence also guarantees you an unbiased audit that uncovers everything that would advantage your plan and its financial standing. You don't get that sort of impartial view from generalist firms working on both sides of the situation. It's why many plans now audit frequently as part of their internal management and oversight. It's advantageous.

 

Implementation auditing 90 days after the changeover to a new TPA or PBM is also a wise move to make for any plan sponsor. Continuous monitoring that keeps the audit software running in the background also pays significant dividends. The flagged mistakes and overpayment recoveries commonly exceed four times the audit price. Those are savings that get the attention of even the most skeptical executives. It also means more consistent and better service to members, which is beneficial. For those with high-deductible coverage, accurate claim payments are also of personal significance.