The Added Value of Medical Claims Auditing

When large and medium-size employers weigh the value of medical claims auditing and continuous claims monitoring service, we remind our clients there are added values to consider.

At TFG Partners, our capabilities go far beyond flagging claim payment errors and assisting with the recovery of overpayments. While there is no doubt those functions alone justify our services, it’s wise to consider all the possibilities of your health plan auditing service. Our claims audit software is designed to improve plan management and serve members better. We can do both during an audit and monitoring service.

An excellent example of a value-add from a 100-percent claim auditing is helping to manage and reduce insulin costs. As plan managers and some members undoubtedly know already, insulin prices have been rising steadily. They also vary widely for products that deliver identical or comparable outcomes from a clinical perspective. However, the cost can vary widely which could be driven due to manufacturer strategies, PBM incentives and a variety of other reasons that prevent your member from getting the best plan value and might increase plan costs unnecessarily.

TFG claim audits and monitoring services can identify various products in a therapeutic class, identify the low- and high-cost products and assess if you are missing co-pay assistance or patient assistance dollars. If there are areas for improvement, we’ll notify your pharmacy benefit manager and can even help identify companies that work with your PBM or can independently provide the necessary help to assure you and your members do not miss out on available co-pay assistance and patient assistance dollars. It helps your plan members, especially if they are in high deductible consumer plans or have co-insurance and at the same time lower plan costs if your PBM isn’t doing it already.

Each Year, TFG Health Plan Audits Add Value

Whether it’s helping plans and their members deal with rising specialty drug prices, insulin costs or other issues, TFG Partners is dedicated to continuous improvement in our claims audits and monitoring. Medical and prescription expenses can be counted on to increase each year, and as treatments become more advanced, claims and the payment rules and requirements become more complicated along with them. Our team has an enormous amount of collective experience with auditing claims, and we bring it to bear in all that we do. Our core service is audits of medical and pharmacy plans protecting the members and plans from unforeseen or unjustified charges, payment errors, fraud waste, and abuse working on behalf of self-funded benefit plan sponsors.

The goal remains consistent: Help members receive the services they are promised and help the plan sponsor meet compliance need as well as control costs so the plan stays affordable.

Our team members come from medical, auditing and IT plan backgrounds, and we were pioneers of the 100-percent audit method back when others were working with random samples. Our approach revolutionized the industry and ushered in a new era of accuracy and value. Ever since we’re refined and updated our claims audit software to keep it an industry leader and best-in-class. Few corporate benefit plan auditors can match the results we provide – and we do it in a way that minimizes the time required for your in-house staff.

We Help Your Members and Protect the Bottom Line

Our mission at TFG is to leave our clients and their self-funded benefits plans in better shape than they were when our work began. Well-managed plans serve their members better and help to manage costs. A good 100-percent medical claims audit like the ones we provide is generally budget neutral – and most times, the errors and over-payments we flag and help recover exceed the cost of our service multiple times. Benefit claim audits serve a plans sponsor’s ERISA compliance needs and are not designed to be punitive for third-party administrators. Viewed properly, they are management tools that help plan sponsors, auditors, and claim administrators to work together on improvements to improve performance across the board.

If it’s time to audit your self-funded health plan or you’re weighing the value of adding a continuous monitoring service, consider all of the benefits. Your self-funded plan deserves a close look at claim payment accuracy, and your members deserve the benefit of add-ons such as insulin price review. All are part of the service provided by a high-performing medical benefits auditing company.