Focused Claim Audits Deliver Valuable ROI
TFG Partners – Client Results
Client Statistics
- Industry: Transportation
- Number of employees (US): Approx. 90,000
- Number of retirees: Approx. 10,000
- Annual healthcare expenditure/payments reviewed: Over $570 million
- Type of audit: Healthcare
Situation
The client needed to assess the claim payment accuracy of their third party administrator. In the past, they had utilized a random selection process and felt that a more focused approach could possibly deliver greater results and higher ROI. The client had an immediate need to curb any wasteful spending and wanted a solution that could become part of an overall process improvement
TGF Partners Solution
This particular client has engaged TFG Partners on an ongoing basis for over 10 years. The effort has been a testimony to the ongoing changes and needs to monitor and improve vendor performance. Annual audits on average have identified over $2-3 million claim payment errors/overpayments. Recoveries of these errors averaged between $1.2 – 1.5 million.
Recently the client has instituted a pro-active “Continuous Quality Improvement” program in close cooperation with the administrator and TFG Partners. Key categories of “likely” error claims are identified and reviewed on-site with the administrator. The problem areas are quantified and prioritized using the TFG Partners data. The client and administrator agree on a prevention strategy ranging from system fixes to operator training and implemented to reduce overpayments proactively.
Outcomes/ Results
The TFG Partners audit identified a series of areas in need of improvement. One example, in particular, was in the area of Medicare coordination of end-stage renal disease. Within nine months of the completion of the audit, the team reduced overpayments from over $300,000 to less than $10,000 annually. Similar results were obtained in the areas of multiple/bilateral surgery charges, co-pays, extended care stays, and other review categories.
This tailored partnership model allows the client to work closely and constructively with the administrator to not only identify areas for process improvements but capture overpayments on an ongoing basis. TFG Partners tracks the reality and success of the initiatives as a part of this ongoing review effort. ROI is very significant (can range from 4-5 times and higher, resulting in a very short payback period within the audit year).