Never Underestimate the Value of Claim Auditing
When looking for ways to serve members well and control costs, health care plan sponsors may overlook the value of claims auditing. For some, the thought of an audit’s cost may be front of mind. But a TFG audit commonly finds recoveries that are four times the project cost when we audit medical and pharmacy benefit claims. Our services are appropriate for all mid and large-size plans, but the more members you have enrolled and the more complex your benefits set up, the higher the probability of claim payment errors.
It’s common to assume that your in-house staff or a third-party administrator (TPA) pays claims with reasonable accuracy, and therefore may not be vigilant enough to see oversight. But no matter how accurate your team or TPA is, there are always cases of missed discounts or rebates, wrong or duplicate billing, errors in member eligibility, problems with plan setup, etc. Periodic claim auditing, ideally followed by continuous monitoring that runs on the same software, can flag these mistakes and lead to the recovery of overpayments.
An even more significant long-term opportunity is identifying setup errors that can be corrected to stop problems that multiply over time. It reduces costs and waste and means fewer incorrect payments that need to be recovered in the future. Plan sponsors with accurate audit data in hand are much better positioned for revising and improving contracts with TPAs and pharmacy benefit managers (PBMs). Over time, these improvements amount to meaningful help in controlling benefit plan costs.
Benefit from Claim Audits are the Industry’s Most Thorough
Even though they include several phases, our pharmacy and medical claim audits move quickly and require very little of your time. The focus is on accuracy and cost-effectiveness in everything we do. Once the initial setup is completed, we review 100-percent of your claims electronically with our TFG proprietary software. It tests all claims against your plan setup and eligibility data, including adjustments and reversals. Our process is a vast improvement compared to earlier random-sample methods.
Next, we add human oversight to closely examine the error patterns that showed up in the electronic claim audit. Individual claims are flagged for closer review when they demonstrate one of the significant error patterns. Also, our error tests are customized to your plan and are different for medical claims and pharmacy benefit claims.
Pharmacy Benefit and Medical Claim Audit Reviews:
- Member eligibility
- Actual charges versus contract prices or reasonable and customary
- Duplicate charges if they exist
- Reconciliation of invoices and administrative fees
- Accuracy of cost-sharing with members
- Payments versus plan maximums and limits
- Adherence of claim payments to your plan’s design
- Coordination of benefits opportunities
- Whether TPAs and PBMs are meeting performance guarantees
Medical and Pharmacy Claims Auditing Each Present Opportunities
The primary checks in health plan claim audits relate to the costs for physician’s fees and testing. Are doctors charging fees that are significantly higher than is customary for the service? If yes, they are flagged for closer review. The second is for testing and whether tests fall outside the standards set by the Centers for Medicaid and Medicare Services. One of the most common is to flag pairs of tests that should not occur together because one covers the other.
In prescription claim audits, we check to make sure prescribed medications are on the formulary and especially whether generics are dispensed in all cases where they are available. One of the most frequent causes of pharmacy plan cost increases is dispensing expensive name-brand products when generics are readily available. Other reviews cover usage patterns, including quantity limits, whether rebates are being appropriately applied, and value versus the maximum allowable price list.
Be Proactive with Claim Auditing for Several Reasons
Depending on your plan size and complexity, our audits customarily take from three to six months from start to finish. The two most significant benefits to plan sponsors are factual data that you can use to recover overpayments and correcting errors in your claim processing system. We verify your TPA and PBM‘s adherence to their contracts during our benefits auditing process and help you meet your fiduciary responsibilities. We’re dedicated to continuous improvement at TFG Partners, and our audits become more accurate and insightful each year. Our clients enjoy many benefits from our service, from finding and flagging individual errors, all the way up to insightful suggestions for systemic improvements in your benefits plan claim processing.
Benefit Plan Claim Audits Returns Value Year After Year
We recommend auditing claims at least annually because there are significant cost savings and member service improvement opportunities with every audit. Ideally, you’ll follow an audit with continuous monitoring service and monthly reporting to provide oversight and keep your plan well-managed. If you’re about to begin working with a new TPA or PBM, an implementation audit after the first 90 days can be crucial. It’s the only way to independently verify that your plan has been set up correctly in the vendor’s system and that you’re receiving all of the contracted benefits. If not, it’s much easier to make corrections early and avoid retroactively cleaning up a costly mess.
Many clients come to us for an initial audit, and once they see the numbers, engage our services for future years or sign on for our continuous claim monitoring service. There is nothing better than monthly oversight reporting that includes benefit audit results and points out trends. It is an outstanding management tool for managing TPAs and PBMs. Our data security is tightly controlled, and with continuous monitoring, you can view your data securely online through our web portal. Experience has shown that any plan paying medical and pharmacy claims will benefit from our service.