Correct Health Plan Claim Processing Mistakes20 December 2023
Employer-funded health plans have much to gain by correcting payment errors (and recovering overpayments), and medical claim audits can help. The first step in fixing any error is finding it, and your chances of doing it improve when you have an auditor double-check claim payments. It’s easy to see why more plans are audited routinely and why the cost containment opportunities are significant. Recent lawsuits filed by large corporate plans against their third-party processors are proof of how much is on the line and the possibility for overpayments. Skyrocketing healthcare costs never let up.
Well-planned and timed claim audits today review 100 percent of payments with an unerring eye for accuracy. When every payment is double-checked with powerful software and methods capable of detecting any irregularity, virtually all mistakes are flagged. Processing error rates are often in the low single digits, but they are no reason for complacency in oversight. Auditing routinely is an excellent decision, and the audit reports help document legal and regulatory requirements, including ERISA and the Consolidated Appropriations Act (CAA). They are a crucial part of following fiduciary best practices.
Claim reviews today are a significant advance of earlier random sampling methods that could flag patterns but missed individual mistakes. Audit reports have become more complete and accurately depict plan performance. When the same firm audits often and produces reports uniformly, it’s easy to compare each period’s performance against others. It’s also a sound way to detect error patterns before they become million-dollar problems. When claim expenses affect the bottom line, auditors can help provide explanations and details for a deeper perspective.
Implementation auditing should also be a priority when you switch your plan to a new claim administrator. Planning an audit three months into your agreement with a new processor is wise. By that time, enough claims will have been processed that an audit will give an accurate assessment. There are opportunities for improvement with prescription medicine and other benefit plans with claim auditing. Each plan and its claim have nuances experienced auditors understand how to navigate. The cost-saving opportunities are always significant, and an audit will always flag more than its price.
Company Name- TFG Partners, LLC
Address- 437 Grant St #1020, Pittsburgh, PA 15219