When millions of dollars are on the line annually, oversight is essential. Nowhere is it more apparent than with medical claims auditing for self-funded health plans. Pharmacy claims deserve a similar close review. Continuing improvement in electronic audit systems brings significant advances and keeps pace with changes in medical billing. It's a vast industry, and employer-funded health plans are hit with new and more complex charges annually. Many claim administrator agreements contain provisions for self-reporting, but it's clear why independent oversight is valuable; it's a way to keep them at their best.
Audit setup matters mightily; if you're in-house managing a health or pharmacy benefit plan, take it seriously. Experienced firms know what to look for and will take your plan's unique provisions seriously. But holding a pre-audit meeting to bring up your goals and concerns is always a wise idea. If you've been unclear about items in self-reporting from your claim administrator, an auditor can examine them more closely and report back with clear findings. You may confirm that everything is running smoothly and handled properly, which is the desired outcome. But if not, you'll have factual data in hand.
When extraordinary events like the coronavirus pandemic occur, claim auditing is an extra defense against mistakes and overcharges. It's common for error rates to be in the low single digits, but finding irregularities can bring meaningful savings; recovering payments made in error is expected. The ideal state is processing system updates and fixes that eliminate the errors. Even the best systems can have glitches; billing practices may have changed, and the system needs an update. Every year, unique situations develop, and auditing catches the ones your processor misses.
Many plans routinely audit or continuously monitor their claim payments to keep tabs on the situation. Repeating error patterns are unusual today, but they can still happen. Sometimes, auditors are the first to pick them up and can help correct the system to prevent future mistakes. It's always preferable to prevent errors than to request repayment for overcharges later. Accurate claim processing is necessary for members with co-payments or other cost-sharing agreements. It prevents them from out of pocketing expenses improperly and helps the plan; it's a function of good management practices.
Company Name: TFG Partners, LLC
Contact Number: 412-281-2228
Address: 437 Grant St #1020, Pittsburgh, PA 15219
