Beyond Dawlish

The trend for many years has been for large employer-sponsored health plans to outsource their claim administration. It achieves economies of scale, and the broader agreement allows members to enjoy the provider network of a major carrier. But there's always the need for oversight, and that's where a medical insurance audit adds value. Running one can confirm the correct things and flag the irregularities. All claims can be reviewed with advanced software, meaning the audit's results will be highly accurate. Therefore, claim auditing today is a valuable performance assessment for health plans. 

When employer-sponsored plans contact third-party administrators and pharmacy benefit managers for claim processing, often the deals include performance guarantees. If yours has such provisions, audits are an excellent way to confirm the agreements are being met. Even very low error rates of a couple of percentage points can add to significant sums, given the high cost of medical services and prescriptions. Auditing routinely to flag any errors the processors' self-policing has missed makes excellent financial sense. It also helps you maintain control when claims are paid externally.

The most effective healthcare plan auditors have dual expertise in auditing and claim processing. Many started their careers with large health plans and have transitioned to auditing. It gives them specialized knowledge that saves time and increases accuracy. Medical and pharmacy claims can be complex, and each plan covers specific services and medicines. When a large health insurance carrier takes on processing, they add the plan to their system. Some items may revert to their system defaults and don't honor a plan's specific details. Auditors can detect and flag irregularities for review.

Besides routine auditing, implementation audits when you start with a new processor, and continuous monitoring service also can be helpful. The start-up phase with a new processor will inevitably cause some errors, and having an independent analysis of where they occur is wise. Monitoring continuously means your plan benefits from an auditor's expertise 365 days a year. Recovering overpayments in real time is easier than working months afterward. It also helps with systemic errors and stops them before they become significant financial losses. Patterns of fraud and abuse also may be caught by monitoring.

Company Name- TFG Partners, LLC

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

Contact Number:(412)-281-2228