TFG Partners, LLC

The coronavirus pandemic impacted various sectors, including health plans. In its aftermath, medical claim audits were essential for understanding the shifts that occurred. Large employers that self-fund employee benefit plans faced challenges as healthcare utilization rates surged, coupled with rising prices. With ongoing inflation and the typical annual increases in healthcare costs, auditing claims has emerged as a practical strategy. While periodic reports from external processors hold value, it's imperative to maintain oversight and review their self-reported findings. An independent auditor's examination often reveals critical insights. The evolution of claim auditing presents a narrative driven by technological advancements. A key advantage noted during the pandemic was the sophistication of audit systems and software, particularly those developed by specialized firms. These tools enabled a review of every claim, verifying thousands of data points. Plan sponsors could customize their audits by adding specific questions beyond the routine points. When the final report is generated, a lot of factual data is available that examines various aspects of the claim experience. As new tests and treatments emerged, alongside their associated costs, a learning curve existed for claim administrators. Initially, confirming the accuracy of these payments was crucial. Identifying patterns of errors early on is vital in preventing them from evolving into more significant, costly issues. It underscores the importance of conducting audits frequently and promptly. Allowing discrepancies to accumulate and attempting to recover overpayments long after they occur can prove challenging. Monitoring these payments within the plan year is more effective when actions can be taken more readily. Alarming stories regarding overcharges surfaced during the height of the pandemic. Although many of them have since been resolved, they highlight the need for ongoing vigilance. Implementing continuous monitoring, where audit software operates in the background and produces monthly reports on claim experience, is a proactive approach. It helps plan sponsors stay informed about cost trends and detect error patterns early, addressing them while they are still manageable. Navigating the complexities of healthcare claim payments necessitates robust oversight to facilitate more effective management.

If you're involved in corporate benefits management, the type of review you select for your medical plan can significantly influence outcomes. Medical claim auditing services that perform comprehensive audits—checking 100% of claims instead of relying on random sampling—tend to yield much more precise results. By incorporating continuous monitoring into your strategy, you can achieve excellent oversight over claim payments, further enhancing accuracy. The advantage of this meticulous approach? Improved service for your plan members and effective cost management. Audits and ongoing monitoring are crucial for plan management. You made a solid start when you finalized your health plan and chose a third-party claim administrator, likely a large health insurance provider. However, it's essential to ensure that your organization isn't overspending and that your employee members receive the care promised by your plan. Uncovering errors and inconsistencies can be quite revealing during your first audit. Many claim administrators make bold assurances about their accuracy and reliability, but nothing surpasses the insight gained through audit and monitoring. Determining the cause of irregularities in claim processing can be challenging. It might be due to a claim processor misinterpreting a plan's specifics or other factors at play. Regardless of the reason, conducting 100% audits and implementing continuous monitoring will provide transparency about the situation. Given the significant financial implications associated with a large, self-funded medical plan, staying informed is critical—especially with events like the coronavirus pandemic, which can swiftly affect healthcare expenses. A thorough audit can help clarify the accuracy of relevant claim payments. Once you've reviewed audit findings, it becomes easier to advocate for a continuous monitoring program. This approach employs real-time audit software to immediately identify errors and patterns in claim processing. Because rising medical costs from self-funded plans can impact financial statements, potentially affecting stock prices and other factors, frequent audits and claim monitoring are essential for maintaining the direction of plans and their expenses. They also underline the importance of conducting thorough audits for improved accuracy instead of relying on random sampling.