Benefit plan claim payments, especially costly ones for health plans, need active oversight to watch for errors. Prescription and medical claims auditing is an excellent way to double-check payment accuracy and the work of claim administrators – third-party processors and pharmacy benefit managers. When
large employers self-fund benefit programs and outsource claim administration, there is significant financial exposure. In at least two recent instances, large corporations have gone to court against the health plans handling their claims alleging overcharges. Audits provide data and allow for oversight.
The concrete and factual information produced by a claim audit is also actionable in any way you, as the plan sponsor, see fit. You can use it for performance improvement conversations with your claim administrators or to recover overpayments. There is no substitute for the knowledge you gain with a well-run claim audit, and many plan sponsors continuously audit their payments for high-caliber oversight. The first time you read an audit report, it’s eye-opening if your processor has self-reported and found no errors. The independent review from auditors double-checks the payments and reports.
Systemic errors were the only ones picked up in earlier random sample audits. Now that technology and systems allow for every claim to be checked, you can expect more complete findings and more opportunities to recover funds paid by mistake. It’s a given that claim payments today are highly accurate, and error rates are customarily relatively low, but you may pick up other cost trends in an audit. When you work with a firm reviewing many plans, they bring experience and a trained eye. What they pick up can save thousands or more, and audits are revenue-positive because of recoveries.
It’s also more common for employer-funded benefit plans to switch claim administrators today. If you do make a change, remember to schedule an implementation audit after 90 days. It’s an excellent way to confirm things are running as planned and performance guarantees are being honored. It’s easier to catch things before they get out of hand than to allow errors to pile up unresolved. While it might have been a common practice to audit periodically in the past, it’s now wise to do it more often. Most plans have learned their lessons one way or another and more aggressively conduct oversight routinely.
Company Name- TFG Partners, LLC
Address- 437 Grant St #1020, Pittsburgh, PA 15219
Contact Number:(412)-281-2228
