Frequently Asked Questions
How TFG Benefits Plan Audits Review 100-Percent of Claims
Why conduct a claims audit? What does it cost?
ERISA requires employers that sponsor health benefit plans to conduct audits from time to time. Plans also continue to change — and even the most accurate claims-processing systems continue to produce significant error rates. An audit is the only way to make sure employees receive precisely what a benefits plan covers and the company is not paying for adjudication errors or non-covered benefits.
The cost of a 100-percent audit from TFG is similar to the cost of a sample-based audit. However, the net cost of a 100-percent audit is much lower: most 100-percent audits pay for themselves in actual recoveries and large employers realize savings that are a multiple of the audit cost.
Why monitor continuously after an audit?
The continuous claims monitoring service provided by TFG is the best tool to manage your benefits claims administration in real time. You’ll have medical and other benefits plans running at peak performance, be better at serving your employees, and manage costs. Problems are caught (and can be corrected) as they occur so that there is never an out-of-control situation. You’ll have peace of mind and the savings captured by a continuous monitoring service is more significant than the cost.
What can we expect the ROI to be?
Traditionally, our clients have realized recoveries of claims paid in error in excess of two to three times the cost of the audit. The return on investment over time, from cost avoidance through process improvements, will be much higher.
How frequently should a benefit plan be audited?
There are no set standards for audit frequency. Most clients prefer to audit every other year, or in the case of larger employers, annually and in some cases quarterly, for continuous quality improvement and cost savings.
Why is 100-percent better than random sampling?
TFG’s 100-percent audit technology re-adjudicates and reviews every claim. We make sure all payments comply with plan rules and identify all exceptions. Also, we can select a strategically focused sample of claims for on-site validation. Tests have shown that we can identify four times as many error categories and up to 14 times as many overpayments compared to random sampling. Knowing what went wrong, with the individual claim, allows us to determine what can be done to prevent future overpayments. It also helps us guide you toward significantly higher recoveries.
In comparison, random sampling applies a statistical selection methodology to the claims data. It provides only a statistically valid understanding of the error types and rates, which creates a reasonable estimate of the percentage of claims that have been incorrectly administered. It, therefore, does not provide practical or detailed information to make significant process improvements and has significant recovery limitations.
Can we conduct a 100 percent audit?
As the fiduciary of your plan, you have the right to choose the type of audit you want. Many administrators try to impose their own rules and limitations, mostly to limit the number of claims reviewed on-site, and staff time needed.
TFG Partners understands the motivations for the rules and has overcome the limitations. We’ve built a reputation for efficiency and accuracy. We have successfully audited all major carriers, using the 100-percent claims review audit process.
How long does it take to complete an audit?
Our average audit takes approximately four to five months, from the moment our auditors receive the data.
What do we need to do during an audit?
Most clients spend no more than two to four days (not consecutively) interacting with us. We pride ourselves in limiting the burden for our clients to only those tasks that are absolutely necessary for a quality audit. We do a lot of work behind the scenes to ensure a level of efficiency.
How will an audit affect our employees?
Audits should not affect employees at all. All overpayment recoveries are at the discretion of the employer. As a result, we typically work with the administrators to recover only at the direction of the employer, such as recoveries from Medicare, and other COB and duplicate payments to providers.