Profile: TFGPartners

The coronavirus pandemic was a transformative event in countless ways. It altered established norms, sparked new trends, and led to the decline of various businesses. Health plans, especially those offered by large employers, faced immense pressure, making medical claim audits increasingly essential. By leveraging medical claim audits, errors can be identified, and valuable data can be collected regarding the overall landscape during this tumultuous period. With third-party processors managing the bulk of claim payments today, effective oversight of their operations is paramount for plan sponsors.

For those involved in managing medical or prescription plans internally, the reliance on reports from claim administrators or pharmacy benefits managers is significant. Having claim auditors on board provides an additional layer of factual reporting, addressing the accuracy of these processors. Although overpayments and discrepancies should be infrequent, only independent reviews can definitively affirm this. Moreover, today's advanced systems enable a thorough review of every claim, allowing plans to recover any overpayments or mistakes strategically based on their value and recoverability.

Engaging in pre-audit meetings presents a valuable chance to discuss specific questions regarding your claim audit. If areas of your plan's expenses, utilization patterns, or performance require scrutiny, an auditor can assist in conducting a more in-depth analysis. Productive audits are tailored to the unique features of your plan, and when aligned with payment accuracy assessments, they yield insightful data and reports. Such insights are crucial when formulating budgets or negotiating new contracts. Recommendations from an auditor can also lead to system enhancements that minimize future errors.

Comparing audit reports from year to year helps track performance over time. It involves understanding how claims are processed, what they encompass, and who qualifies for them. The value of independent audits lies in having an outside entity analyze your administrator's operations. While companies may have self-policing mechanisms, verifying their accuracy is essential. Given the high costs of medical services and medications, knowing whether errors occur is vital. Well-managed plans gain performance benefits, and audits equip managers with the necessary data and insights to drive improvements.