Healthcare Audits Confirm Accuracy and Find Mistakes
Company Medical and Benefit Claims Auditing | TFG Partners
When medical claim auditors review 100 percent of payments with proprietary technology and systems, they uncover a lot. The good news is the expected accurate payment of most claims, but the more significant opportunity lies in the bad news – the mistakes they flag. You see an outstanding return on investment when audits lead to overpayment recoveries up to four times their price. It also helps self-funded plans improve their claims administration, usually handled by third-party administrators. Improvements in technology, specifically in auditing software, bring accuracy improvements each year.
When you audit medical claims, there are multiple opportunities for funds recovery and systemic improvements. One of the first ones is to do quality benchmarking which means comparing your administrator against best practices and standard quality levels. The next one is flagging errors, including patterns that can be eliminated with systemic improvements. After those comes recovery opportunities for overpayments and mistakes. Oversight helps plan sponsors work with TPAs on advances in many areas and set goals for the future. You'll confirm compliance with federal and plan fiduciary rules.
Independent claims auditors bring the most potential because they have no other allegiances. They also specialize in the field and continuously improve their systems and processes. One of the most significant post-audit results is validating the performance guarantees written into claim administration agreements. If your TPA is falling short of industry standards for accuracy, it's an opportunity to direct improvements to get your claim payments on track. An electronic review covering 100 percent of claims will consistently outperform random sampling and ensure that all members are treated fairly.
Most large employers that sponsor benefit plans audit their pharmacy benefit payments as vigorously as their medical claims. Multiple opportunities exist with prescription plan audits, including pricing and discount guarantees (are they being honored?), rebates, and scans for fraud, waste, and abuse. From these reviews, there can be suggestions for adapting your formulary to take better advantage of opportunities in the marketplace. Things change each year, and staying on top of the options takes time. Auditors working in the fields daily can alert you to what other plans are doing more effectively.