Cost and care management are dually significant priorities for self-funded medical and pharmacy plans. There are thousands of variables to consider for everyone involved in their management. That's why reviewing claims with a medical and RX audit is crucial. Auditors equipped with advanced software can provide an independent analysis. It's excellent oversight for third-party claim administrators and pharmacy benefit managers. Their systems are sophisticated and accurate, but things can slip through the cracks. When auditors make an independent review with their systems, it can be an eye-opener.

Claim auditing has become an increasingly important management tool for self-funded plans offered by large employers. They depend on others to administer their claims, giving an open checkbook to some extent. When you audit successive quarters or years, you can compare various trends and pose questions the audits can answer (or confirm). Self-reporting by claims processors is valuable, but comparing it with independent findings can be more instructive. Over time, you have a clear picture of many things. It's an excellent way to manage costs and the care delivered.

If you're considering using claim auditing more frequently and viewing it as a management tool t rather than for compliance, you may wonder about the cost. The best auditors routinely find recoverable overpayments and other mistakes totaling four times the price for the audit. It varies by plan, but nearly everyone adds to their budget after an audit. It's a revenue generator rather than an expense hitting the bottom line. As a result, plans are auditing more often or having their claim payments monitored continuously. Receiving monthly reports from an auditor analyzing claim payment activity is helpful.

Pre-audit meetings and interviewing audit firms can also allow you to ask questions and learn more about the value of claim auditing. If you're in-house at a plan sponsor trying to manage an outside processor, few things are as helpful as factual data. The information audits produce is the basis for negotiations and meetings with your vendors to ensure you're receiving the maximum value of their services. Reviewing 100 percent of claims rather than random sampling is also typical today. You have a much better overpayment recovery and error correction opportunity with 100 percent reviews. 

Company Name - TFG Partners

Address- 437 Grant St #1020, Pittsburgh, PA 15219

Contact Number: (412)-281-2228