How New Hospital Price Lists Can Help Medical Claim Auditing

The medical plan audits and continuous monitoring we provide at TFG Partners are expected to benefit from the Federal Hospital Price Transparency Rule that took effect on January 1, 2021. It requires hospitals to post prices online for 300 services, including MRIs, heart procedures and surgeries, joint replacements, new patient visits, and lab tests.

In another effort to help you protect your members and the plan from overcharges, we’ll use the data to verify pricing further and work to reduce over-payments while helping members find lower-cost options. Those favoring the new requirement, including the Centers for Medicare and Medicaid Services, want price transparency to help slow the rise in health care costs. We welcome the new price data, especially if it is standardized and centralized.

At TFG Partners, we leverage every opportunity to improve the quality and value of medical claim audits and continuous monitoring services. As hospitals make their price lists available online, we’ll be able to check every single claim paid for the approximately 300 price-transparent services. Historically, it was only possible to audit sample claims by requesting contract details – so the price lists will dramatically expand our reach to most high-frequency procedures. The data may also help plan sponsors inform their plan members and provide better information for members to get the best value, especially for high deductible consumer-driven plans. It also helps the plan sponsor guide their employee-plan members to the highest-value providers, saving both the member as well as plan resources.

TFG Checks Co-Pays and Provides Data for High-Deductible Plan Members

Using the price lists, our claim audits and continuous monitoring service can check all charges and plan specific co-pays. We will flag overcharges to employees and the plan sponsor. Each can be targeted for restitution and gives self-funded health plans additional value from our service. It’s also an example of why it’s best to review 100-percent of claims – a practice we pioneered and improve continuously every year. There is no better method than checking every claim with advanced software and human oversight on our end. And with the federally required hospital price details in our systems, we will compare actual charges against hospital price lists to further improve our work’s accuracy. And to avoid cost-shifting, we will continue to review all other claims and validate pricing particularly for high-cost procedures against contracts as part of the on-site audits and contract reviews.

We welcome the price lists and the greater insight about costs at each hospital. The data will add insight for our reports about where employees and their dependents get their medical care and how much they spend. Our mission is to help our clients to identify ways for their employees to find savings, which is especially helpful for employees in high-deductible plans. With cost increases never slowing, this is a key first step as more transparency from hospitals can only be seen as a good thing.

Who Will Benefit Most from Published Hospital Prices?

Plan sponsors and their employees each can benefit from uniform pricing that is transparent and allows for comparison. Of course, the concept of shopping around has more relevance to elective and non-emergency services but will help overall. It also can foster a consumer mindset about shopping around for hospital services that might not have been present previously. Some experts question the likelihood that consumers will overwhelmingly shop around, but their healthcare plan sponsors, acting as their proxies, are expected to take a more active interest. And now, there might finally be actionable information about what the true net costs are. And with the 300 services and procedures as a first step, pressure will increase to unveil easy-to-use actionable information on more complex services.  Once available, plan representatives with more significant expertise will undoubtedly analyze cost, add relevant quality and outcomes data and present that information in ways that patients can also start making more informed decisions about getting better quality and cost of care for these more challenging services.

Our TFG Partners medical plan auditing and continuous monitoring are the best way to track and review health care services and costs – and get the simple, easy-to-use information that help you improve claim administration, and stop paying for overcharges and costly errors. Adding hospital price lists as another checkpoint for claim payments gives us an additional way to help our clients and their employees.