Medical Providers Gain from Claim Auditing

Healthcare billing is complex and detailed, which means providers can miss revenue when billable items are missing on invoices or coded incorrectly. Medical claim audits can also benefit providers because of the potential for mistakes to reoccur. Long thought to be a tool of payers, most notably self-funded plans sponsored by large employers, the value of auditing is broader these days. Patterns of errors could just as easily work in the payer’s favor as the provider’s. Therefore, running an audit to review items billed and paid makes sense in several ways. Accurate medical billing is in everyone’s best interest.

It also holds that the likelihood of errors increases when the system is under stress, and the recent coronavirus pandemic was such an event. Audits for the next several years will look back at that period and compare it to subsequent experience. There’s also much to be said for working with an outside auditor separate from your internal systems. Reviewing billing and claim payments with their software can pick up irregularities your system might be missing. When you work on something daily, it can be more challenging to detect some errors that outsiders will catch. 

Audit reports and their clarity have much to do with the value of a claim review. When findings are presented in straightforward and easy-to-understand terms, it saves time in implementing the recommendations. If errors or ambiguities are embedded in your system, getting them fixed will make an immediate improvement. Previously lost revenue becomes captured revenue which helps the bottom line with no changes in your workload. Those opportunities are the most significant ones to arise from an audit. They’re also helpful in satisfying some payer and regulatory requirements regarding claim payments.

Continuous monitoring of claim payments is also trending, with many plans trying to tighten their oversight and controls. It allows sponsors to see real-time results of their third-party administrators and pharmacy benefit managers in action. The added stress of the coronavirus pandemic on the system caused irregularities as new treatments and services were introduced quickly. As news headlines trumpeted, some were wild overcharges that needed to be questioned immediately. Monitoring claim payments continuously gave sponsors the required data to be proactive, putting that at a significant advantage. 

Company Name- TFG Partners, LLC

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

Contact Number:(412)-281-2228