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With the continuous rise of healthcare costs, self-funded medical and prescription plans increasingly seek ways to manage and control expenses. Running a medical and Rx audit to doublecheck claim payments has emerged as a crucial strategy, proving to be cost-effective and potentially profitable. Through the thorough auditing of claims, organizations can recover audit costs with recovered overpayments. The trend has garnered attention from managers overseeing medium to large self-funded healthcare plans, mainly due to its potential for significant recoveries, which bright down costs.

 Employer-funded plans today are predominantly managed by third-party administrators (TPAs) who handle claim processing. This reliance on TPAs highlights the importance of oversight, as TPAs are typically held to performance and accuracy guarantees within their service agreements. However, depending solely on self-reported data leaves plans vulnerable to unreported errors, which has surprised many plan managers upon discovering substantial variations in audit findings from what TPAs had been self-reporting. Identifying errors often brings systemic fixes to prevent future similar errors.

 The swift and often unpredictable rise in costs, particularly amidst events such as the coronavirus pandemic, has led to an increased trend of more frequent auditing. This adjustment signifies a departure from the past auditing practice more to comply with regulatory requirements such as Sarbanes-Oxley or ERISA. Sponsors have realized the myriad benefits of close plan oversight and management, which directly impact plan members. Equally important, auditing ensures the consistency of claim payment practices for all members, a critical factor in engendering trust and satisfaction.

 While TPAs and Pharmacy Benefit Managers (PBMs) may have the best intentions, it's acknowledged that everyone makes errors, and sometimes those closest to the situation overlook them. Therefore, the value of clear reports based on an auditor's data cannot be overstated. Audit findings are solid evidence, offering a basis for informed negotiations for future TPA service agreements. When selecting a claim audit firm, it's paramount to prioritize finding one entirely independent, possessing unique expertise and working in the field each day. Leveraging the experience of such a firm impacts the results achieved.

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Companies that handle medical and pharmacy claim processing for employer self-funded plans must undergo periodic audits, ensuring regulatory compliance and financial oversight. Medical claims auditing is becoming increasingly frequent each year and is vital for overseeing the complex process of medical claims payment. The value of medical claims auditing is particularly significant for larger plans, where the impact of inaccuracies can be substantial. Doublechecking coding accuracy is a critical aspect of claim audits, as it directly affects a plan's costs and providers' revenue—correctness helps everyone.

Accuracy is paramount, so audit firms must ensure that any claim processing system is accurate, reducing time and expenses for all involved parties. The necessity of oversight in such a complex process explains the growing frequency of audits. The latest development is the introduction of continuous monitoring services, which provide monthly reports on claim payments. This proactive approach presents a significant benefit to self-funded plans, helping keep claim payments on track and enabling increased scrutiny, especially during unexpected events such as the coronavirus pandemic. 

Identifying and recovering funds from overpayments presents substantial financial opportunities for self-funded plans. Early detection through audits makes recovery more accessible and more effective, underscored by the significance of frequent auditing and monitoring. For-profit corporations self-funding their benefit plans are susceptible to claim costs impacting their bottom line. Therefore, having accurate data available is crucial to confirm the general accuracy of claim payment operations and fulfill fiduciary responsibilities to ensure that expenditures benefit plan members. 

Incorporating technology into claim audits has achieved significant accuracy gains over the past two decades. Software advancements have fine-tuned capabilities to review claim payment details at a granular level, offering near-miraculous improvements over the earlier days of random sample auditing. Although human oversight continues to play a role, it now involves reviewing the results of electronic sweeps. Today's systems audit faster and require less time and human intervention than earlier versions, resulting in a win-win situation for all stakeholders involved.

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Today, it's widely acknowledged in health plan management that 100-percent claim audits yield more accurate results than random sampling. A healthcare audit with improved accuracy identifies more errors, discovers additional overpayments, and generates more precise reports. For plan sponsors, this presents an opportunity to oversee third-party administrators and pharmacy benefit managers. The increased precision of the audit makes it a more robust management tool and helps plan sponsors manage their claim costs. Given the complexity of the processing function, oversight is warranted. 

Advancements in the proprietary software used by claim auditors have driven numerous improvements, allowing for a more comprehensive review of details. The cost of the audit service is also budget-friendly, as it can result in recovering up to four times the price of the service. Those working in the field who have not experienced a 100-percent audit find it a pleasant surprise. The previous random sampling method was more time-consuming and less precise. Today's audit software can process thousands of claims and produce actionable, accurate data, an excellent management tool. 

In addition to the objective of maintaining well-managed health and pharmacy benefit plans, sponsors must grapple with the ongoing rise in healthcare costs. Managing costs while ensuring plan members receive excellent care is the overarching objective, and audits shed light on performance. It's common for companies today to keep audit software operational at all times for real-time monitoring of claims. The ability to catch and rectify errors quickly is valuable, and it's also easier to recover overpayments shortly after they occur. Managing discrepancies months or years after the fact is more challenging. 

The evolution of claim audits is truly impressive, considering they started as a matter of regulatory compliance. Improved technology also reduces human involvement in the review process, with advancements occurring yearly. Third-party administrators and pharmacy benefit managers naturally exercise greater care in their work when they know oversight is present. Audits serve as a method to confirm whether they are meeting performance guarantees. Given the dollars on the line and the responsibility of offering an employee medical plan, auditing often is always wise.

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Something new arises with health planning billing errors and related irregularities when you think you've seen it all. Medical claims auditing is one of the most effective ways for employer-funded plans to run oversight and keep their claim administrators working at peak accuracy. Many TPA agreements these days indeed include self-reporting on errors, but how well can it work when the system that makes the errors is used to detect them? It's evident to anyone that independent oversight from a third-party auditor will give you more accurate results. Today's auditing systems are highly accurate.

Knowing where to look for errors is the most obvious reason to hire a specialist firm. People who build and run the systems that review medical claims daily are closest to it and stay abreast of changes and new developments. The COVID pandemic has upended many things, and medical billing is one of them. Story after story about astronomical costs appeared. But in less intense times, overcharges and overpayments occur, and policing them in real time needs to happen. It also explains why many plan sponsors audit more frequently today or have their claim payments checked monthly or more often.

Sophisticated audit software can pick up even buried mistakes that routine reviews might miss. If you're in-house with a plan sponsor, use your pre-audit meeting to voice any concerns or considerations you want your auditor to review. If you audit a medical and pharmacy plan simultaneously, you'll have the best opportunity to maximize your savings. You can easily expect the recoverable mistakes an audit will find to be several times more than its price. It's surprising to many people at first, but seeing is believing, and after your first claim review, you'll understand – that even low error rates are worth improving.

Human nature is to work harder when there is active oversight, which makes the case for claim auditing. Plans that review their payments independently can easily expect better performance from third-party administrators and pharmacy benefit managers. No one enjoys being called on the carpet; doing it has a short- and long-term impact. You also can operate more knowingly as a plan sponsor when you have an auditor's report in your hand with the facts. Nothing speaks louder, and you'll feel more confident knowing you have an objective opinion from an audit firm with only your interests in mind. 

 

 

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When large corporate or nonprofit employers sponsor their employee benefits, they put millions of dollars on the line. Healthcare plans are among the most expensive, and it's why medical claims auditing and pharmacy claim reviews matter so much. There is a fiduciary responsibility to pay claims accurately, and with outside firms handling it, auditing is the most effective way to conduct oversight. It provides an objective third-party review of all payments and their accuracy, or not. Given the many factors affecting plans today, it's easy to see why beefing up oversight is imperative.

When you're working on plans and budgets for medical and pharmacy plans, claim audit reports are insightful. Compared to self-reporting from administrators, they complete the picture and provide independent confirmation. Today's sophisticated audit software can answer most questions you can pose about plan performance. It can also find opportunities for savings and serving plan members better. You can quickly see why plan sponsors audit their claims more frequently and double-check their payments monthly. Auditors can run their systems unobtrusively in the background continuously.

Pre-audit planning allows you to have an information exchange with your audit firm. You can bring up areas of concern and listen to their suggestions about places of interest based on experience and past work. Electronic claim reviews today are more sophisticated than ever and powered by advanced systems that quickly bring the audit to the finish line. They also render easier-to-read (and understand) reports that give clear insights into the findings and analysis. Having factual performance data for meetings and negotiations with your claim administrator also informs that process. 

If you audit claims only when required for regulatory compliance, you're missing opportunities and may work farther in arrears than is optimal. Timely reviews that flag errors and irregularities shortly after they have occurred can facilitate easier recoveries if there are overpayments. Finding repeating mistakes earlier also means correcting systems and more easily avoiding million-dollar problems later. It adds value if you're looking at auditing from a compliance, cost containment, fiduciary best practices, or member service standpoint. Double-checking claims always returns more money than the service's price. 

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The thing about any random sample is that it's just that: random (and unpredictable). It means no two random samples turn out alike. Therefore, when reviewing self-funded health plans' claim payments, medical claim auditors who review 100 percent are more than a step ahead. When every claim is double-checked against the plan's specific provisions, irregularities are flagged, and a clear picture of performance emerges. Understanding where processors are making errors, if they are, is essential to oversight. Independent auditors with powerful claim review software are best positioned to help. 

In the wake of the coronavirus pandemic, gone are the days when claim auditing was chiefly a regulatory and compliance function. Having seen the significant value it generates, plan sponsors have begun auditing more frequently as a strategic plan management tactic.  Some have even opted to monitor their claim payments, medical and pharmacy, as frequently as monthly. Having real-time reports with irregularities flagged is excellent insurance against million-dollar problems. Nothing is better than catching mistakes as soon as they happen. It's also easier to recover overpayments.

Electronic claim reviews have steadily improved in recent years, which means less staff time to complete a claim audit. When advanced software can find and flag most irregularities, the initial reports bring accurate results that are quickly useful. When you add the skilled review of experienced claim payment reviewers, you'll see unprecedented accuracy for no increase in cost. In fact, audit prices are often far less than the mistakes they flag. It's why plan sponsors increasingly turn to claims reviews to manage their plans better. With outside processors making the payments, there is a need for oversight.  

When you interview and select claim audit firms, their independence and specialization matter. Boutique firms specializing in the field have a handle on current trends and are often better at learning and appreciating your plan's unique provisions. When they set up their audits, keeping your plan's specifics in mind and ensuring they are included will matter. It improves audit quality and accuracy, which benefits you in the final report. It better meets your needs for oversight and gives you insightful data on your plan's performance – correct payments and irregularities.

Company Name- TFG Partners, LLC

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

Contact Number- (412)-281-2228