For the foreseeable future, medical and prescription medicine costs will escalate significantly every year. It puts significant financial pressure on employer-funded benefit plans. It also explains why they routinely schedule a medical claim and Rx audit to double-check the cash outflows. With nearly all claims today paid by third-party administrators (TPAs), there is an obvious need for oversight. The possibilities for overpayments and irregularities in claim processing are making significant news lately. One large corporate employer with self-funded medical plans is suing its claim processor for billions.
The complexity of medical billing and the never-ending list of discounts and incentives in pharmacy charges creates opportunities for errors. Claim administrators promise to self-report them as part of their service controlling error rates, but are they thorough? Only outside, independent auditing firms can verify the reporting. Ideally, you want a firm that specializes in claim auditing and actively works in the field daily. Each plan has unique provisions, but knowing where to look in general is a significant advantage. Checking 100 percent of claims rather than random sampling also improves effectiveness.
Their reports are impressive as claim audit software and systems continue to be improved and refined. Pre-audit questions are an excellent idea and help focus the claim review on selected areas. There was a time when only claim groups with similar errors were ripe for recovery, but today it's possible to go after individual mistakes. There's also a significant management value in active oversight. TPAs and pharmacy benefits managers (PBMs) will naturally work more carefully when they know their work is being double-checked. The sums of money are significant, and reviewing claim payments is vital.
What's also better about today's advanced systems is the electronic review's ability to get closer to the final report. It means less staff time is required, which is helpful for organizations where people are stretched thinly. All claim reviews need human involvement and insight, but it's useful when the electronic review takes things further. The added detail in audit reports is also beneficial for financial staff in explaining budget variances. Understanding the trends driving the increases is helpful if costs exceed the planned budget. When you audit routinely and with excellent reporting, it helps overall.
Company Name- TFG Partners
Address- 437 Grant St #1020, Pittsburgh, PA 15219
Contact Number: (412)-281-2228
