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.