The Essential Healthcare Claims Audits

  Description- At TFG Partners, we’re one of the leading prescription claim auditing companies with highly effective proprietary software and methods. Our prescription plan audits review 100-percent of payments for unrivaled accuracy. When other companies are random sampling claims or cutting corners, we’re at work reviewing every payment electronically and with human oversight.  

The coronavirus pandemic underscored the key function of healthcare auditing companies. As new treatments emerged and healthcare costs fluctuated unpredictably, organizations regularly found themselves paying first and relying on audits to provide accountability. These medical claim and pharmacy benefit manager audits uncovered overpayments and enabled negotiations to recover funds from excessive charges. The knowledge acquired from thorough claims reviews has become critical, informing more accurate and competent processing of health plan claims both now and in the future.

Even prior to the pandemic, there was a growing trend toward more frequent and thorough healthcare audits. Employers sponsoring health plans, whether nonprofit organizations or corporations, have had to contend with increasingly limited budgets. Identifying and correcting errors in claims processing has become more important than ever, since it directly affects cost control. Ongoing process improvements and the correction of costly mistakes help offset rising healthcare expenses. Additionally, accurate claims payments are necessary for guaranteeing fair and consistent treatment of all plan members.

Today’s claim audits frequently reveal errors that can amount to four times the cost of the audit itself. Systematic audits help tighten plan management and enable swift correction of systemic errors. Addressing mistakes soon after they occur leads to simpler recoveries and minimizes the effort needed to resolve any future questions. Advances in software have also produced a significant impact, lessening the necessity for manual review and increasing the accuracy of electronic audits. When the initial automated review is highly precise, it speeds up the entire process and increases confidence in results.

Independent specialty audit firms are now leading the claim review industry. These firms employ professionals with deep expertise in carrier operations. The lack of conflicting allegiances means their sole focus is on serving your plan’s best interests. While many firms operate ethically, there is peace of mind in knowing that your audit partner is aligned exclusively with your goals. If you have not worked with such a firm, reviewing a comprehensive report after a 100-percent claim review can be eye-opening. The detailed data they provide can be immediately leveraged to improve plan performance.