Medical Claims Auditing Services
Accurate Claim Audits with Unmatched plan improvement and overpayment reduction
Heightened legal and regulatory scrutiny combined with skyrocketing costs are making today’s healthcare landscape increasingly challenging, seriously impacting employer-funded health plans and their members. Therefore, flawless claim administration is essential.
At TFG Partners, we are industry leaders in medical claims auditing, making us an excellent partner for your company’s health plans. Our dedication is unrivaled, and we have pioneered many of today’s best practices for employee benefit claim auditing.
- Unmatched accuracy in medical claim reviews
- Accurate data for fiduciary and regulatory responsibilities
- 100% of claims reviewed and easy-to-read reports
- The industry’s best return on investment (ROI)
- Objective, fully independent standing as an audit firm without carrier or broker affiliations
- Real-time continuous monitoring service available
When you have us on your plan’s side, independently reviewing your third-party claim administrator, you can rest assured that the industry’s most thorough oversight of your claim payments is in place.
Medical Claim Audits by Definition
Medical claim audits are thorough reviews of payments made by healthcare plans to providers on behalf of members. They are essential when corporate and nonprofit employers self-fund medical plans and are required to schedule periodic audits to ensure compliance with government regulations.
While claim reviews began as a regulatory and compliance function, they have evolved into a valued management tool thanks to increasing accuracy and efficiency. Today, audit reports help employer medical plans assure members get all the benefits they are entitled to while achieving optimal financial performance, member service, and compliance.
How Claim Auditors Work: Our 5-Step Method
At TFG Partners, our auditing process comprises five critical steps to ensure your health plan’s medical claims are paid accurately and in accordance with plan provisions.
The accuracy of audit data and the value of the audit report depend on a careful, thorough set-up keyed to your plan documents. All TFG Partners claim audits are customized to suit each plan’s needs. We’re experienced in auditing all third-party claim processors and know how to double-check all relevant areas. But you’re encouraged to bring requests to the pre-audit meeting.
The audit process begins with an intensive electronic review of all claims paid during the period under audit. Examples of items we will review and flag include improperly coded or ambiguous claims, those without sufficient medical need/intent, and any with pricing or charges above agreed rates. Leveraging almost 35 years of hands-on experience to drive our technology, TFG Partners systems not only review every claim but identify the highest volume of exceptions, using 3-4 times as many error detection algorithms than others while limiting potential false positive findings.
We provide meticulous analysis that yields more accurate, actionable audit results. This phase includes summaries of potential overpayments, insights into the reasons behind errors, strategies to mitigate future occurrences, and, most importantly, an independent and objective assessment of your claim administrator’s performance.
Based on audit data and reports, we’ll help you ensure your plan complies with ERISA (Employee Retirement Income Security Act) and Sarbanes-Oxley regulations, as well as newer requirements from the Consolidated Appropriations Act (CAA). Claim audit data is also valuable, as it helps ensure your plan upholds its fiduciary duties in an increasingly litigious environment.
When leveraged optimally, our audit report suggestions can lead to systematic error prevention strategies to protect your plan. We have also provided data and information that our clients have used to recover millions of dollars in overpayments and errors.
Why Choose TFG Partners?
Partnership is a guiding principle at TFG Partners, whether within the firm or in our work with clients. The experience and insight we bring to the table is a direct result of our people and how they work together. Our mission is to be the ideal medical claims auditor for your plan’s oversight needs.
Independent Auditors
We are fully independent from insurance carriers, claim administrators and the advisors that designed plans or selected the carriers. Our only priority is your company’s health plan and its best interests. TFG Partners professional record is highly respected and the firm is accepted as auditor with audit privileges with all major and secondary Third Party Administrators as well as Pharmacy Benefit Managers.
Specialization
Claim audits are our only business, and as a result, our expertise and knowledge of the field are deeper than those of generalist auditors. Many of our senior team members have prior health plan experience and are well-versed in every aspect of claim administration.
A Record of Success
TFG Partners has a long-standing reputation for excellence and is recognized as an innovative industry leader. Our clients include mid-sized and large self-funded medical plans, and our proprietary electronic claim review systems have set the benchmark for success in our field.
Advanced Techniques
Recognize that not all auditing methods are created equal. We were pioneers in reviewing 100% of claims, an approach that significantly enhances the accuracy of our audits. It has led to recovery opportunities that far exceed the price of our services.
Why Audit Healthcare Claims Frequently?
Also, Ask About our Continuous Monitoring Service
Employer health plans are required to deliver promised services to members, and reviewing claims paid is an excellent way to ensure they are. It’s the same for fiduciary responsibilities – claims audits can confirm compliance.
Regularly auditing claims uncovers hidden errors and inefficiencies that result in overpayments. Our audit reports are eye-opening, helping you plan to rectify ongoing issues, continuously improve performance, and hold costs down.
Today, many third-party administrator agreements include accuracy and performance guarantees. But are they meeting them? An accurate, independent claim audit is the best way to be sure all promises are kept.
Most claim administrators deploy sophisticated fraud prevention measures, but no system is infallible. With advanced auditing techniques, we can detect types of fraud and abuse that might otherwise go unnoticed.
Several large plans have been hit with class-action lawsuits alleging fiduciary breaches. Well-managed plans with sponsors who run active oversight, such as claim audits and monitoring, are better positioned to defend themselves if challenged.
Medical Claim Audits Tailored to Your Plan’s Needs
In today’s rapidly evolving healthcare landscape, effective medical claim audits and continuous monitoring are essential components of successful plan management.
At TFG Partners, we have led the way in medical and pharmacy claim auditing with our advanced and proprietary systems and 100% audit methodology. Together, they deliver unmatched accuracy and ROI to our clients.
When you put your plan in our hands, we’ll help you confidently manage your healthcare expenditures while providing the promised care to your members.
Take the first step in adding oversight to your medical claims process by working with TFG Partners. Contact us today to learn more about how our auditing services can benefit your employer-funded health plans.
Frequently Asked Questions
How often should a medical claim audit be conducted?
The frequency of audits can vary based on the size and complexity of your healthcare plan, but conducting at least an annual audit for larger plans and biennial audits for smaller organizations is recommended to ensure compliance and identify any potential overpayments.
What is your Continuous Monitoring Service?
Many employer-funded plans continuously monitor medical claim payments with the same software and systems used for audits. It’s excellent oversight and catches mistakes and irregularities when they are in their infancy – long before they become significant problems.
How do medical claim audits identify fraud and abuse?
Auditors analyze claim patterns, review claims thoroughly, and employ sophisticated software to identify inconsistencies that may indicate fraudulent activities, such as repetitive billing for services not rendered.
What types of claims are audited?
Typically, all types of medical claims can be audited, including hospital claims, physician services, outpatient services, and more. Our full-service approach means we review every claim paid by your health plan.
How does TFG Partners ensure confidentiality during audits?
We take confidentiality seriously and adhere strictly to HIPAA regulations to ensure that all patient information and claim details are kept secure and private.
Should my plan conduct an audit if we are satisfied with our claim administrator?
Yes, even if you are satisfied, it is essential to conduct an independent audit, and it is required for regulatory compliance. Audits provide valuable insights and confirm that your claims are being managed accurately and effectively.
Are my prescription claims included in the medical plan claims audit?
Medical claims audits fully cover claims for medications billed under the medical plan such as J-code injectables and specialty drug claims. These claims represent fully half of all specialty drug costs for a typical employer. Separately, prescription plans benefit from separate 100 percent claims audits, and most plan sponsors conduct their audits of the medical plan and the prescription plan simultaneously.