TFG Partners Performs 100% Medical Claim Audits
Medical claim auditing reviews the payments a given health care plan has made to providers on behalf of its members during a previous year or other defined amount of time. They are most commonly conducted by self-funded medical plans required to audit themselves first by government regulations and now because auditing is an excellent plan management tool. Self-funded health care plans are typically sponsored by large employers, both corporate and nonprofit. Medical claims auditing was conducted initially by random sample, and today most of the best claim auditors review every payment.
Self-funded health plan claim auditing has become more frequent as plans increasingly outsource their payment infrastructure to third-party administrators (TPAs). The TPAs are typically large managed care plans with extensive provider networks (doctors, specialists, hospitals, outpatient surgery centers, etc.) that can also be used for the members of a self-funded plan. A claims audit provides in-house staff at a large employer with meaningful oversight of their medical claim payments. While TPAs commonly make accuracy and performance guarantees, the only way to confirm the actual results is with an audit.
How the Medical Claims Auditing Process Works
How Do Medical Claim Audits Work?
The goal of the best medical bill auditing service is to work independently, review claims, and report results as independently as possible – which means very little time is required from a self-funded plan’s in-house staff. A full-service audit with four parts is typically the most effective and begins with reviewing the plan’s benefits. Step two is the audit and analysis of the results. The third and fourth steps are advice on improvements to claim processing and recovery. The funds recovered are from over-payments, claims paid in error, and fraud and abuse. Better audit firms always include following through to recovery.
Advances in technology have made the 100-percent method of medical claims auditing the gold standard for accuracy and return on investment (ROI). It’s superior to random-sample audits and can produce exponentially more accurate results and lead to the recovery of more funds. When every claim is reviewed, many more error patterns and individual mistakes are flagged. The sophistication of today’s audit software also means there is no sacrifice in speed and efficiency when review all claims instead of only a few. It’s common for an audit to recover funds three to four times more than its cost.
TFG’s Medical Claim Auditing Produces an Exceptional ROI
Conventional thinking about medical claim audits is that they are budget neutral – but a TFG Partners auditing services produce a far more substantial return on investment. Our clients typically recover funds from claims paid in error that are two to three times the audit cost. Over time, the savings from process improvements are much more significant.
Do Health Care Plan Auditors Differ from Each Other?
When you interview benefits claim auditors, be aware there is a difference. It’s wise to look for independence and specialization (expertise) because they are two of the most important determiners of outstanding performance. Because many self-funded health plans are large, the scope of the work is significant enough to support firms that become specialists in auditing medical claims. They are staffed by people with deep experience in health insurance claims and who know the methods and technology that are required to audit with speed, precision, and accuracy. You’ll notice a difference. At TFG Partners, we’ve pioneered many of the advanced claim audit methods widely considered best practices today. We’re industry leaders and specialists in the field. Not many claim auditors can match the accuracy and efficiency of our work. Our list of satisfied clients spans a wide range of mid and large-size self-funded medical and other benefit plans sponsored by corporations and nonprofit entities. We were the first to develop a method to review 100-percent of claims, and any other firm doing today has followed our lead. We’re the best choice to improve your plan performance.