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Skip Random and Go for 100% Claim Audits

The thing about any random sample is that it’s just that: random (and unpredictable). It means no two random samples turn out alike. Therefore, when reviewing self-funded health plans’ claim payments, medical claim auditors who review 100 percent are more than a step ahead. When every claim is double-checked against the plan’s specific provisions, irregularities are flagged, and a clear picture of performance emerges. Understanding where processors are making errors, if they are, is essential to oversight. Independent auditors with powerful claim review software are best positioned to help. 

In the wake of the coronavirus pandemic, gone are the days when claim auditing was chiefly a regulatory and compliance function. Having seen the significant value it generates, plan sponsors have begun auditing more frequently as a strategic plan management tactic.  Some have even opted to monitor their claim payments, medical and pharmacy, as frequently as monthly. Having real-time reports with irregularities flagged is excellent insurance against million-dollar problems. Nothing is better than catching mistakes as soon as they happen. It’s also easier to recover overpayments.

Electronic claim reviews have steadily improved in recent years, which means less staff time to complete a claim audit. When advanced software can find and flag most irregularities, the initial reports bring accurate results that are quickly useful. When you add the skilled review of experienced claim payment reviewers, you’ll see unprecedented accuracy for no increase in cost. In fact, audit prices are often far less than the mistakes they flag. It’s why plan sponsors increasingly turn to claims reviews to manage their plans better. With outside processors making the payments, there is a need for oversight.  

When you interview and select claim audit firms, their independence and specialization matter. Boutique firms specializing in the field have a handle on current trends and are often better at learning and appreciating your plan’s unique provisions. When they set up their audits, keeping your plan’s specifics in mind and ensuring they are included will matter. It improves audit quality and accuracy, which benefits you in the final report. It better meets your needs for oversight and gives you insightful data on your plan’s performance – correct payments and irregularities.

Company Name- TFG Partners, LLC

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

Contact Number- (412)-281-2228

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