Overpayments are other irregularities that can strain health plan budgets, and medical claim audits are one way to correct them. Discovering and reporting each mistake is one of the chief outputs of a claim review and can save plans significant sums. With nearly all claims today paid by third-party processors, it leaves employer-sponsored plans in the dark. Even though most processors self-report, having an auditor’s independent verification is the best way to understand plan performance. It’s similar to pharmacy benefit plans, where rebates and promised discounts can easily slip through the cracks.

The ever-changing medical billing landscape keeps claim processors on their toes, and many are to be commended for keeping error rates low. But recently, there have been lawsuits and disputes with plan sponsors alleging claim administrators have overpaid on their behalf. Some are multi-year scenarios involving millions of dollars. Early and frequent auditing can play a role in keeping things on track and avoiding extreme situations that end up in court. Facts and data are the best tools to keep everyone in the equation fully apprised, and they are what audits produce; they’re an excellent management tactic.

The power of an audit depends on how accurately it is set up and the systems it runs on. That’s where specialty firms come in that review claims as their only business. They’re experts in medical invoices and have equal experience in other benefit plans, including pharmacy. The deeper an auditor drills down with each claim, the greater the chances of catching an error. The power of today’s electronic claim review systems is impressive and allows for detailed analysis in seconds. After setup, thousands of claims can be checked quickly with zero human involvement; all suspected irregularities are flagged soon. 

Implementation auditing is also getting increased attention for good reasons. With the stakes as high as they are, employer-sponsored health plans routinely change claim administrators. After a switch, it’s wise to run an audit at the three-month mark to see how things are performing. It’s an excellent time to catch and correct systemic errors that repeat and add up quickly. But with today’s 100 percent claim auditing, flagging individual errors is also essential and can make a difference. Recovering overpayments makes sense, and cleaning up a batch of smaller ones can bring meaningful savings.

Company Name- TFG Partners, LLC

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

Contact Number- (412)-281-2228