The value of medical claim auditing for self-funded health plans is affirmed in many ways each year – it always pays to review what’s happening with your third-party processor. The latest example to make TPA oversight a topic in the news is a class-action lawsuit filed against UnitedHealthcare Group (“UHCG”) over out-of-network payments. The giant health carrier (and claim processor for self-funded plans) is accused of systemically underpaying benefits for out-of-network claims in violation of ERISA’s fiduciary obligations.
When you have a firm like us audit your medical claims, we double-check every detail on every claim to keep you informed and more in control. Our reviews can pick up details similar to the ones in the UHCG lawsuit, which accuses UHCG of using deeply discounted re-pricer rates instead of contractually specified competitive rates. The suit alleges UHCG shifted more than $1 billion in out-of-network costs to plan members since 2016. More concerning if the allegations are true, the company charged self-funded plans a fee for negotiating lower shared-savings rates to benefit members; fees that increase for UHCG as the re-priced rates come down.
We Catch Details Because We Review 100-Percent of Claims
Our TFG Partners healthcare claim audit software and methods are among the most sophisticated in the industry, and we were pioneers of the 100-percent process. When we check every claim, every detail is noticed, and we can compare against many provisions and standards to ensure promises are kept. That also applies to what our self-insured clients are paying to out-of-network providers, including the discounts and savings fees charged by their administrator. Our claim audits find as much as four times in savings compared to the price for the service, and they work as well for pharmacy benefit plans as they do for medical claims. When we catch problems in their early stages, you can more quickly recover overpayments and keep your processors honest.
TFG Claim Audits Have Lasting Advantages
Health Plan Cost Containment
Suggested Member Service Improvements
Easy-to-Read Detailed Audit Reports
Minimal Required Staff Time from Your Team
Budget-Friendly and High Return on Investment
In addition to our system capabilities, we are thorough and focused on assuring that your plans are correctly set up and all members receive their benefits accurately. Our process reviews all your unique medical and pharmacy plan designs and company-specific details so that our audit takes every plan and adjudication requirement into consideration. Our highly experienced medical claim auditors work in this field daily, and as health plan claim auditing is our only business, you leverage the most current knowledge and deep expertise. As a result, you receive a level of effectiveness and care you won’t find with many of our competitors — we’re dedicated to continuous improvement in all that we do.
Follow a Claim Audit with Continuous Monitoring
We audit medical claims using a proprietary system that’s well-suited to run continuously. A continuous monitoring plan is a significant advantage for self-funded medical and prescription plans. We catch and flag irregularities when they occur so problems are corrected before they become significant issues. Real-time audit data about your claim payments sheds light on many areas, is an outstanding plan management tool, and it provides valuable oversight of outside claim administrators.
Recent news about the class action lawsuit against UnitedHealthcare Group brings the added value of claim auditing into the spotlight as we begin this year. But it’s always a good idea to audit and monitor your plan’s claim payments for many reasons. Your advisory and partner relationship with a firm like ours is one of the best safeguards against the surprise of an out-of-control problem. Good plan management depends on information, and our mission is to deliver needed data at an excellent price.