Trust and Accuracy Matter in Medical Claim Audits1 November 2023
If you’re a large payer in today’s healthcare system, the financial exposure is enormous, similar to pharmacy benefits. Therefore, large employers self-funding their medical plans look to healthcare auditing companies to help them stay on track. What wins the respect of providers is precise and accurate data about fact-based irregularities and errors. When an audit arms you with solid information, it’s a more straightforward path to recoveries and corrections. Once systemic mistakes are caught and corrected, smaller individual items flagged for review can add up to significant numbers depending on your plan’s size.
The evolution of claim audits from a compliance issue to a strategic oversight and management tool has occurred over time. Technological advances have led the way as the option for 100 percent audits has overtaken random sampling. When every claim and payment is reviewed at the micro level, audits uncover much more actionable information than they could previously. The possibilities have not escaped the notice of large payers in the form of employers that self-fund their plans. But as the value of highly accurate auditing has become apparent, more parties in the claim payment equation do audits.
Part of what distinguishes the most effective healthcare auditors is their ability to audit all kinds of plans, regardless of their size and type. What you check for in medical claims is different from pharmacy plan auditing. Bringing the proper knowledge and specialization to each increases accuracy and effectiveness. The goal is always to present concrete facts that cannot be disputed. It helps payers request paybacks for overcharges and other irregularities. Performance guarantees from outside claim processors keep the error rate in the low single digits, but the dollars lost can still be significant.
Understanding the medical billing system also matters, and it’s why specialist audit firms often have the edge over more general companies. Because they are reviewing claims daily, a knowledge base builds more quickly. It’s also worth their while to bring in people with large health plan experience who understand the nuances and changes in claims administration. There is no substitute for real-time knowledge. If you’re a firm’s client just learning the ropes in a detailed business, it’s easy to see how you could pay the price. When you’re working with people who know already, it saves time.
Company Name- TFG Partners, LLC
Address- 437 Grant St #1020, Pittsburgh, PA 15219