With medical and prescription costs among the most expensive employee benefits, getting the most from a healthcare audit matters. It presents opportunities to recover overpayments and correct costly mistakes. Auditing claims is a detail-oriented endeavor, and even though an outside audit firm will handle it, plan managers should understand the finer points. Conducting oversight of claim processors is one of the most effective cost-containment tools available to health and pharmacy plan sponsors. Auditing each claim involves rechecking dozens of data points, and minor errors increase over time.

All audits begin with an electronic review handled by the audit firm’s system. Software and technology advances in recent years have greatly improved the accuracy, and now most firms review 100 percent of claims paid. The speed and efficiency of today’s claim reviews are eye-opening for anyone who has been around long enough to recall the days of random sampling (which also ate up staff time scrutinizing the results). It’s also helpful to understand that the return on investment with auditing (and continuously monitoring claim payments) is significant. Audits find savings of about four times their price in many cases.

Parties on all sides of the medical claim and payment systems can find a benefit in auditing. For years, payers in the form of large employer-sponsored plans had the most interest in auditing. But medical practices and other providers are finding a benefit in audits. The ability to flag system errors, or patterns of errors, can be helpful. Repeated mistakes, whether overbilling or underbilling, add up over time and negatively affect all parties. The optimal scenario is for all claims to be paid accurately. When they are, it helps keep finances more stable, and payers and providers benefit in the long run. 

While trying to understand more about maximizing claim audits, it’s essential to bring up the firms specializing in the service. They have both audit and health plan knowledge and experience that puts them in an unmatched position to deliver superior results. General auditors have a tax and financial focus that is only part of what’s needed in claim reviews. Understanding medical coding and the complexities of patient services and covered items is extensive. Trusting the claim review to a firm without deep knowledge of the systems and potential trouble spots can lessen the effectiveness. 

Company Name- TFG Partners, LLC

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

Contact Number:(412)-281-2228