Claim Auditing At The Micro Detail Level

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Company Medical and Benefit Claims Auditing | TFG Partners

Paying health and pharmacy benefit claims is a complex endeavor and getting it right is essential given the high costs involved. Medical claim auditing has become increasingly sophisticated, and the improved ability to review all claims down to the micro level matters. It allows plan sponsors and their audit firms to identify hundreds of variables to screen. It will enable nearly any question about claim costs to be answered factually, and the results analyzed and compared against other factors. It gives plan sponsors unprecedented ability to oversee affordable rates and monitor their claim processors.

The coronavirus pandemic, with new tests and treatments, quickly coming online in a chaotic emergency, heightened the need for detailed audits. Few times in memory have the health care system so unexpectedly and suddenly been confronted with such a widespread and expensive crisis. Employer-sponsored health plans bore the brunt of much of the cost, and analyzing the expenses in the aftermath became essential. It also brought into more precise focus the significantly improved capabilities of claim auditors that were known but perhaps less appreciated. Since then, detailed audits have been more frequent.

Flexibility is also crucial in claim auditing because not every plan's claims are processed on the same system. Adapting audit capabilities to different platforms and configurations becomes essential, along with custom setups that can be adjusted to each plan's provisions and standards. There is no one-size-fits-all claim audit, and anyone who suggests there is needs to understand the situation better. The finer points also become critical because of the savings and discounts promised by claim administrators. Allowing them to self-report is information, but only an independent third-party audit can verify them.  

More needs to be said about the importance of audit setup. Along with the quality of the auditor's system and methods, it's the determining factor in improved results. A careful and thorough structure that considers a plan's aspects brings much more valuable data to light than a quick audit setup with less specialization. It also speaks to the value of long-term relationships with auditors. When they become closely affiliated with a health plan, they develop a more profound understanding of its nuance and unique aspects. There may be suggestions for plan changes based on the findings of claim audits.

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