More Accurate Claim Audits Strengthen Your Plan

Company Medical and Benefit Claims Auditing | TFG Partners


Self-funded medical and pharmacy benefit plans have many advantages for large employers, both corporate and nonprofit. But as costs continue to skyrocket, healthcare auditing companies are vital allies in managing the plans well. With most claim administration outsourced to third parties, in-house people need audit reports to manage their vendors. Even tiny error rates of a couple of percentage points quickly add up to large numbers. While processors commit to catching and correcting errors, only audits can confirm they are doing it – and more accuracy in auditing always matters.

When you work with expert claim auditors who specialize in the field, they take an interest in your plan and advocate for its best interests. It includes careful audit setup and a high degree of customization to pick up on the finer points of your medical and pharmacy plans and their claims. Outsourcing claims administration, generally to a large carrier with excellent negotiated rates and provider networks, makes sense on many levels. But oversight becomes an important consideration when you don't directly control claim payments. Even if your processor self-audits, an independent review may reveal more.  

Advances in technology and software continue to improve the accuracy of claim audits and can also be used to monitor continuously. Especially since the coronavirus pandemic, many plans have ongoing monitoring services. It has the audit software running unobtrusively in the background and brings monthly reporting on the findings. It's an advantage to request reimbursement for overpayments and payments in error shortly after they occurred. It's far easier and more successful than working months or years after the fact. It also provides added detail to cost and utilization trends earlier.

The unique skills and knowledge specialist claim auditors bring to the table help them find and flag irregularities specific to medical and prescription plans. Each has particular opportunities for corrections and recoveries that become meaningful when taken together. Accuracy in audits requires the right approach for each plan, and the same goes for other claims you may have them audit, such as dental. The value of a claim review increases with its accuracy and ability to alert you to all mistakes and irregularities. If you're the person in-house managing a large self-funded medical plan, audit it soon.