Setup a Claim Audit and Get the Facts

Posted on 16 March, 2024 by TFG Partners, LLC

When administrators pay thousands of claims daily, even the most accurate ones will make errors. Scheduling and running a healthcare audit routinely makes sense and helps double-check their work. Today's best claim auditors are more like management consultants who analyze plan performance and suggest improvements – along with the standard work of flagging errors. Medical billing is necessarily complex, and large employers that self-fund their benefits plans have millions of dollars on the line. Reviewing claim payments has always made financial sense and is more beneficial today.

Finding claim auditors who bring specialization and expertise to the table always means you'll have better results. When they've audited every third-party administrator in the business and learned their systems, they know where to look. If your TPA self-reports about accuracy, it will be interesting to compare their report against the one from an auditor. Pre-audit meetings also allow you to bring items of interest (and concern) and ensure the claim review will cover those points. Each plan has unique provisions, and then they're loaded onto a TPAs system; something can fall through the cracks.

People who are knowledgeable about healthcare auditing also keep prescription plans in mind. Although their payments follow formularies and are less complex than medical billing, audits do turn up various irregularities. For example, many pharmaceutical companies promise discounts and rebates, but do they credit them as promised? Auditors closely scrutinizing your payments can quickly answer the question and continue watching in subsequent audits. Surprising as it sounds, it's also common to find expensive brand-name medications dispensed when the formulary calls for generic equivalents.

Medical plans have fiduciary responsibilities to pay their claims accurately and serve members well. Today, class-action lawsuits arising against large employer-funded plans challenge their payments and service delivery. In every case, claims auditing provides factual data to help defend against legal challenges and keep your plan performing as it should. Allowing claims processors to operate without close oversight opens the door for many problems to arise. In addition to looking retroactively, you can count on audits to help in the future, meaning error mitigation potential.