Medical Claim Audits Matter More in Tough Times

Doublecheck for Overcharges and Improper Billing

Anyone having anything to do with the U.S. healthcare system would love to hear good news about healthcare pricing and billing. But so far, none appears to be on the horizon. Instead, there is a steady drumbeat of news about a lack of accountability and trust. Everyone agrees there is a problem, but the solution(s) remain elusive. It puts employer-sponsored health plans in an incredibly tough position.

At TFG Partners, we know from experience as medical claim auditors that the horror stories are true because we help our clients spot overcharges, incorrect billing, and other irregularities every day. The woes also extend to pharmacy claims, and running a careful Rx claim audit is just as essential.

Active oversight of health plan claims is more essential today than ever before.

If you’re looking at your medical and pharmacy expenses and can’t believe what you’re seeing, we can help. Claim audits are one of the best and most effective defenses and remedies against untrustworthy billing because we review every claim paid and the prices charged. Our services always end up budget-friendly because we flag recoverable overcharges worth more than the price of the audit.

Recent Billing-Integrity Survey Results

When words like “indefensible” come up related to hospital bills for some services, it’s clear providers and payers are far apart. Published reports about a recent survey of payers by the National Alliance of Healthcare Purchaser Coalitions included a range of strong opinions about medical and pharmacy billing.

• More than 2/3 don’t trust hospital billing practices
• More than 1/2 are concerned about PBM administration conflicts
• Nearly 3/4 question whether hospital charges are reasonable

The 172 survey respondents from various employers and industries also discussed the impact of out-of-control healthcare costs on their employees and salary practices. When medical and pharmacy costs take a bigger piece of the pie, less is available for salaries to attract and retain top talent. This also means cost-sharing takes more out of employees’ pockets as they contribute to healthcare costs.

The Financial Stakes are Enormous

As you consider how your health and pharmacy plans may be affected, the numbers are startling. In widely read reports on JAMA Network, well-informed experts place healthcare spending waste at about 30 percent – and those numbers occur after years of efforts to reduce waste and overpayment.

Adding layers of oversight and putting providers and claims administrators on notice that you are watching is vital. Plan sponsors must be proactive and go a step beyond surface-level information in analyzing and managing their plans’ performance. Putting it another way, industry experts today commonly talk about too many “fox watching the henhouse” scenarios in healthcare billing.

Claim Auditing Gives You Factual Insight

As legislators and payers try to address the issues, with some going as far as supporting hospital price regulation, plan sponsors are left to deal with the current situation. Our audits today produce reports with deep perspective and analysis of expenses, services, and cost trends. It’s also why we recommend Continuous Monitoring Service in which we audit your medical and pharmacy claims in near real-time.

Everyone agrees it’s better to catch things early than wait until million-dollar problems pile up. Auditing medical and pharmacy claims also contributes to fiduciary best practices, which has become another topic of concern. ERISA sets standards for benefit plan management to protect employee rights. As a result, the reasons to audit and monitor your plan’s claims increase yearly.

If you’re interested in learning more about our claim audit capabilities and the data and reports we produce, we’re always pleased to provide an initial consultation. TFG Partners specializes in sophisticated claim auditing for employer-funded benefit plans, working with outsourced claim administrators.

We’ll bring our expertise and advisory to the table, and you can pose questions that our claim audits can answer. Our audit and monitoring systems continuously advance, and we’re always on the leading edge.