Continuous Medical Claims Monitoring with CMCM Service
Medical plans, billing, and contracts are complicated. Continuous Medical Claims Monitoring,or CMCM,from TFG makes sure your Third-Party Administrator (“TPA”) processes claims correctly. We track and flag issues early, and notify you and your TPA about incorrect plan adherence, administrative errors, and missed opportunities to coordinate benefits and reduce plan costs. Until now, most plan sponsors have only been able to assess the level of TPA performance long after the fact using audits.
Although audits will continue to play a role, we now enable benefit managers to stay ahead of the curve and receive feedback throughout the plan year — so corrections can be made near real-time and not long after the plan year has ended.
Our CMCM service, is the logical extension of a 100 -percent medical claims audit from TFG. We collect your company’s medical claims daily, weekly, or monthly and provide:
- Invoice validation: You can immediately confirm your bills are correct, and your company is not paying for medical claims or administrative fees that were never incurred by your members;
- Discount Checks: Our service reviews average discount levels In-Network as well as Out-of-Network so you can monitor how your TPAs network is delivering promised savings;
- Adjudication accuracy: Detect any medical or technical exceptions from duplicate claims payments to missed coordination of benefits with Medicare or other coverage;
- Cost outliers: From overly high-cost J-Code specialty charges to surprise Out -of -Network and recently COVID-19 related billing, our system flags outliers that require follow up by the TPA.
In a nutshell, with both the CRM and CMCM services from TFG Partners, your company will receive concise, easy-to-read reports. We summarize a special executive synopsis for your C-suite and provide continuous access to the plan score on the internet as well as any red flags that may require follow up. It will help your plans deliver peak performance.