Implementation Claim Audits are Opportunities

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TFG Partners is a healthcare claims audit and monitoring firm that has been leading the industry for nearly 30 years.

Among the many points at which you can implement medical claim auditing, perhaps one of the biggest opportunities is shortly after implementation. Moving claim administration to a new processor brings opportunities and promises. But are they being fulfilled? Only a thorough review can give an accurate answer. As medical costs and services become more complex, paying claims properly is an increasingly difficult undertaking. Large health plans that act as third-party administrators on behalf of self-funded plans have considerable expertise, but even with experience, they aren't infallible.

Scheduling an implementation audit for 90 days after a new processor begins work is the ideal timing. When a substantial number of claims have been paid on the new system and doublechecking the accuracy makes the most sense. There's great value in stopping errors before they multiply into larger problems. It also may lay bare anomalies that hadn't been detected with prior processors or systems. When you hire an independent specialist claim auditor, they arrive with systems and experience that can detect even minor issues. A well-functioning claims payment apparatus is the result of many details.

There are audit firms of many types, but most people in the benefits administration field agree that smaller independent firms may be best. You can find firms that only audit claims with staff members who have experience at a large health and pharmacy benefit plans. Their deep understanding of the systems and processes uniquely positions them to develop systems and methods that are the most accurate. Their independence also helps them pout their plan client's interest number one with no other competing allegiances. Larger firms may have relationships on both sides of the equation.

A highly effective implementation audit helps things get underway smoothly; it bodes well for efficiency and cost savings. Independent oversight to confirm accurate claim processing is the only way to verify any assurances are met. It's also excellent support for fiduciary responsibilities in for-profit corporates self-funding their health plans. Material increases in claim costs can affect quarterly earnings reports and the bottom line. Therefore, keeping costs in check and having explanations for budget overages or other unexpected events is beneficial. An implementation audit can help all of the above.