New TPA and PBM Set-Ups Need Claim Audits

TFG Partners is a healthcare claims audit and monitoring firm that has been leading the industry for nearly 30 years. We’re fully independent and work with Fortune 500 and mid-sized companies to improve benefits plan performance. Our service is unique because it includes audit, analysis,

Implementation auditing is essential 90 days after new health and pharmacy claim processing set-ups. It's also accurate medical claim auditing services can independently verify that third-party administrators and pharmacy benefit managers have their systems set up correctly. It's the way to catch minor errors before they become million-dollar problems. TPAs and PBMs famously offer performance guarantees, but only auditing 100-percent of claim payments can verify the promises. Plan sponsors are often surprised to know that claim audits lead to system improvements and recoveries up to four times the audit's cost.

Experienced auditors recommend the 90-day point for an implementation audit because there is enough claim processing experience to give a clear picture. Reviewing claims sooner doesn't provide enough data to maximize error reduction. Waiting too long causes other complications when they can detect error patterns that could have been corrected earlier. TPA and PBM providers with excellent track records welcome auditing to fine-tune their claim processing methods. If you have one resisting an audit or trying to prevent one, it's a potential red flag about their performance. Your plan needs accuracy.

What audits do best during the implementation process is detect places where a plan's set-up isn't accurate in a much larger multi-client system. Nuances and specializations aren't always easy to program, and TPAs and PBMs have complicated systems requiring specialization for each client. Even with the best intentions and a sincere effort, there are errors and omissions nearly always. When claim auditing picks them up early and leads to system corrections, it can save time and money for all involved. The financial exposure is significant with medical and pharmacy claims in most cases.

Large employers that are for-profit corporations with tens of thousands of employee plan members have quarterly earnings reports to consider. If higher than expected medical and pharmacy claim costs affect the balance sheet, it can become an issue on an analyst phone call. It's one of the reasons plans today audit more often than called for in regulatory requirements. It's a management tool that helps plan sponsors keep their claim costs on track or understand trends driving increases. It's why implementation auditing is so important, and many follow it with a continuous monitoring service.