Continuous Benefit Claim Monitoring Service
Run the Best Oversight of Your TPAs and PBMs
Absolute accuracy in medical and pharmacy claim payments is required in the current business, legal, and regulatory environments. At the same time, employer-funded plans outsource medical and pharmacy plan administration, which keeps day-to-day management out of their control.
As a result, for the plan sponsor and fiduciary, running oversight is essential to ensure third-party administrators (TPAs) and pharmacy benefit managers (PBMs) are doing their work as promised. Periodic medical and Rx claims audits are the gold standard for oversight, but what if there were a way to do it even better and easier?
The answer is TFG Partners’ continuous benefit claim monitoring service or ”CM”.
- Ensure your medical and Rx plans operate correctly at all times.
- Detect errors in claim payments and adherence to plan designs and formularies.
- Reduce HR burdens and audit related tasks by reducing time requirements while improving oversight
Gain Accurate Insight into Claim Administration
The fiduciary and regulatory responsibilities related to medical and pharmacy benefit plans continue to increase each year, not to mention the need to manage chronically skyrocketing expenses. That’s why continuous claims monitoring makes so much sense — and it’s highly cost-effective.
Continuous monitoring (CM) of claims, running on our proprietary audit systems, combines powerful electronic analytics and expert human oversight that deliver results.
- Monthly reporting
- Actionable intelligence
- Practical suggestions for improvement
Why review claims continuously? Audits provide detailed information, but the data is retrospective. Audits take time to manage. With CM service, you’ll receive data on claim payments and plan performance in near-real time. It allows you to manage more proactively and effectively in today’s challenging and more litigious environment, where government agencies and members are increasingly holding plan sponsors accountable as fiduciaries of their benefit plans.
Why Monitor PBMs and TPAs Continuously?
Primary advantages of running our CM service on your medical and pharmacy plans:
- Catch overpayments early and prevent future ones.
- Confirm negotiated prices are honored.
- Ensure discounts and guaranteed rebates are delivered on pharmaceuticals.
- Examine claims for duplicate or excessive services.
- Find systemic errors and fix them during and not after the plan year.
Additional value-added advantages:
- Data to underpin your required fiduciary oversight
- Easy-to-read reports to empower in-house plan managers
- Informational support for financial recovery; overpayments, etc.
Your PBM: Why Monitoring It is Vital
Today’s prescription drug market is legendarily complex. Transparency in pricing, or lack thereof, and the business practices of PBMs are under continual scrutiny as legal challenges multiply.
Common issues range from discount shortfalls and rebate discrepancies to reclassification or improper dispensing of higher-priced name-brand products. When continuous monitoring is running, we track and report changes and irregularities as they occur, ensuring you’re always on top of the situation.
- Capture missed or under-credited discounts or rebates.
- Detect pricing errors or overpricing.
- Review prescriptions or categories with cost discrepancies.
- Find payment errors.
- Avoid missing recoverable overpayments.
While screening every filled prescription, continuous monitoring provides independent oversight of plan design, formulary and financial aspects. CM drives PBM accountability by providing human resources and financial teams with plan performance summary reports and actionable data to improve decision-making.
Why Choose TFG Partners?
As the pioneer in full-service, 100-percent medical and Rx claims audits, we offer the most accurate continuous benefit claim monitoring. We keep your plan’s claim payments up to date in near real time – and the systems and methods we’ve developed are renowned for their accuracy.
With savings often exceeding four or more times the cost of our services, having us continuously review your Rx and medical claims makes economic sense as savings outpace costs, while at the same time the cash-flow can be improved. We’ll also help you serve members better and meet your fiduciary responsibilities.
How Does Setup and Pricing Work?
- Starting up a continuous monitoring service is easy and handled almost entirely by our staff.
- Once your company signs the service agreement, we work directly with your TPA and PBM to establish a secure data exchange.
- We load all plan provisions and formularies into our system. We can receive claims and produce your first reports within six to eight weeks of kickoff.
- As new benefit claims enter our system, we will work with your TPA and PBM to ensure the review is accurate and accounts for all provisions of your plan.
- The service is billed based on a straightforward fixed fee at the start of each quarter. The price is highly cost-effective and, in most situations, far lower than the savings you’ll net.
What are Continuous Monitoring Reports Like?
The continuous monitoring reports you receive are insightful and actionable, easy to read, and often packed with suggestions and recommendations for improvement. Our focus is on compliance, cost reduction, and better service for your members.
Monthly Status Reports and Quarterly Financial Performance Reviews are designed to keep you informed about progress and plan performance gaps. These reports are available online for your team members, making it easy to access the latest information at any time, from anywhere.
Annual Summary Reports cover all TFG Partners findings, including any areas of disagreement with your TPA or PBM, and a complete exception analysis and a detailed results report, provided as soon as possible after the close of your plan year.
Ready to Start Monitoring Your Claims Continuously?
Continuous Monitoring Service for medical and Rx claims is a unique and valuable service that leverages all of claim auditing’s potential to keep your benefit plans running at peak performance.
In simple or quarterly monthly internet-accessible reports, you’ll see your plan’s cost and utilization trends alongside any red flags that require attention. Irregularities and discrepancies are reported to you, your TPA, and your PBM so they can be addressed and corrected promptly.
- Help members receive medical care and medicines as promised.
- Avoid overpayments, duplicate services, and missed discounts or rebates.
- Better understand significant cash flow and utilization variations.
Additionally, because all data is available, TFG Partners can easily add services such as market checks or assist with the RFP process. When you work with us for CM and other benefits consulting services, we’ll help ensure your plan receives the most up-to-date and competitive pricing and contract terms, allowing you to take advantage of the latest market opportunities and pricing.
Interested in learning more about how continuous benefit claim monitoring can work on your company’s behalf? Please call or contact us online today.
Frequently Asked Questions
What is continuous benefit claim monitoring?
It’s an ongoing service that checks every medical and Rx claim for accuracy and compliance shortly after it is paid, helping employer-sponsored health plans manage costs, improve cashflow while reducing errors, and delivering more accurate employee benefits.
How is this different from an audit?
A traditional audit is a one-time, resource-intensive event — often contested by the carrier and settled long after errors occurred. TFG operates continuously, catching discrepancies in the same billing cycle they happen. Corrections are made in real time, without end-of-year disputes or lengthy recovery negotiations.
I am a self-insured client; how will this help me?
TFG’s CM will catch errors in real time — pricing mistakes, contract misapplications, are flagged the same cycle they occur while the reporting helps recover money you’re owed. It also reduces HR burden — the service runs in the background; your team simply reviews a monthly report and fulfills your fiduciary responsibility.
How much time and involvement does it take from our HR team?
Minimal. Setup is quick, and the service runs in the background — no lengthy contracting, oversight, or carrier meetings. It lowers the HR burden, you simply reviews reports; when discrepancies are found, the consultant and carriers are notified directly to resolve issues in real time, avoiding dragging refund disputes past the close of a plan year.
How quickly can we get started?
Setup takes six to eight weeks after sign-up, with our team handling most of the process for you.
What makes TFG Partners different?
TFG Partners combines proprietary technology with deep auditing expertise to provide continuous monitoring with near real-time reporting, independent oversight, and numerous plan improvement opportunities.
How does pricing work?
The service is billed as a straightforward, cost-effective fixed fee based on plan size at the start of each quarter.
What makes TFG Partners different?
TFG Partners is fully independent. Unlike periodic audits or consultant-driven analytics, we review 100% of your prescription claims every month, catch errors in real time, and hold carriers directly accountable and help to get things fixed.