The coronavirus pandemic put a unique stain on many systems in society and none more heavily than employer-funded health plans. They took a beating, and many lessons were learned, as medical claims auditing has shown us in the pandemic’s aftermath. There were new tests and treatments with wildly varying price tags and higher utilization across the board. Hospital stays involving ventilators and other costly treatments all put into focus the enormous value of a tightly managed medical plan. Nowhere was the need more evident than with claim payments, which cover how plans spend money.

Medical claim auditing has long had a role in healthcare cost containment and continues to do so as auditors have improved their systems and technology. They can review every dollar a third-party administrator pays and flag irregularities. Because most TPAs are large health plans with established infrastructure, it’s easy to see how a plan’s unique provisions may be overlooked. Your plan only spends what it should when claims are correctly processed. When there are errors, it always leads to higher costs and no additional benefit. Plans must audit and spend their funds accurately.

Large employers today commonly have auditors check their medical claim payments continuously. It’s one of the best ways to run oversight on claim administration. With millions of dollars on the line annually, a claim audit can routinely find errors with exponentially more value than the price for the service. It’s made claim auditing a management function as much as one for compliance. However, audit reports document things for ERISA requirements, the Consolidated Appropriations Act (CAA), and other laws and regulations. It demonstrates why there is significant value in frequent auditing.

In addition to medical claims, auditing pharmacy claims is a significant opportunity. They have different potential errors, but the opportunities are just as substantial. The most obvious ones to watch for are dispensing name brands when generics are available and on the formulary. However, rebates and discounts are also promised for many medications, and auditors can check to see that they are credited as promised. When you routinely run oversight and call errors to the attention of providers, it’s common for their service and accuracy to improve – there’s more incentive when you’re watching.  

Company Name- TFG Partners, LLC

Address- 437 Grant St #1020, Pittsburgh, PA 15219

Contact Number:(412)-281-2228