• TFG Partners, LLC

  Moments When Claim Audits Matter More

  Posted by TFG Partners on February 18, 2025 at 12:06 pm

  In the aftermath of the coronavirus pandemic, which significantly disrupted the nation’s healthcare system, many aspects were (and continue to be) revisited and evaluated. For large employer-funded health plans, utilizing medical claim auditing services for thorough reviews is critical. Additionally, having the same firm assess pharmacy claims is advisable. The unprecedented expenses and utilization stemming from the pandemic threw budgets into disarray, affecting both short-term and long-term financial planning. Since then, getting costs and expenditures back in line has been a balancing act.

  Third-party claim administrators and pharmacy benefit managers managing claims were under immense strain, making it essential to scrutinize their work. As we move beyond the pandemic, it’s important to note that specific government-sponsored medical plans are beginning to negotiate medication prices, which may influence the market. There is concern that drug manufacturers will increase prices for other plans to recover lost profits. In this context, frequent audits and continuous monitoring of claim payments are prudent. Having up-to-date data regularly available provides needed plan oversight.

  Choosing the proper claims audit firm is crucial. Opting for a firm specializing in this area with advanced electronic review capabilities can make a significant difference. When audits are set up meticulously, systems can identify potential errors down to a granular level. It allows for the detection of recurring systematic mistakes and the opportunity to recover individual errors. Unlike in the past, when minor, isolated errors often went unnoticed due to random sampling, today’s audits can treat these errors as part of the recoverable amounts, resulting in a more significant financial impact.

  While it may be tempting to let a knowledgeable and competent claims auditor operate independently, engaging and asking questions is beneficial. Making the audit team aware of your plan’s specific needs and challenges in recent years can enhance the process. With your input, the audit setup can focus more closely on the priority areas for your organization. Today, claim audits serve as strategic management tools for health plan sponsors, making a detailed examination of payments essential given soaring healthcare costs. By doing so, you can expect to see improvements over time.

  TFG Partners replied 5 days, 5 hours ago 1 Member · 0 Replies
• 0 Replies

Log In to Reply