After COVID, Medical Plans Need Claim Audits

Company Medical and Benefit Claims Auditing | TFG Partners


Many things have changed in the aftermath of the coronavirus pandemic – some have become obsolete, and others have increased in value. Without a doubt, medical claim auditing is more crucial than ever for large employer health plans that are self-funded. The pandemic brought increased claim volume for many plans and some astronomical overcharges. Third-party administrators (TPAs) have effectively caught many of the overcharges and errors, but only the oversight of a 100-percent claims audit can confirm it. Well-managed plans that serve members fairly and control costs audit themselves frequently.

The trend of outsourcing claim payments to TPAs has brought efficiencies and given plans the benefit of administration by health carriers. But it's also removed a plan's staff from direct management of claim processing. Even with the performance guarantees of TPAs, there can be errors and uncaught overcharges that an audit will detect. Many COVID tests came in at varying prices, some far above what is reasonable and customary. Hospitalizations for coronavirus illness also often end up in the ICU, where costs are categorically higher. All of these things point to the need for more frequent audits.

As challenging as the cost increases for medical services and prescription medications continue to be, today's auditing software is keeping up. It's now routine for most firms to review 100-percent of claims and achieve an impressive level of accuracy. If your TPA has let some things slip through the cracks, your auditor will pick them up when you hire the best firm. Independent auditors specializing in medical claims have the most expertise and can conduct a review with very little time needed from in-house staff. It's a no-brainer when audits and monitoring recover as much as four times the cost.

If you manage a self-funded employed medical and pharmacy benefit plan and aren't yet continuously monitoring claims payments, consider it soon. A monitoring service will run on the same audit software and give you a real-time view of your claim payment activity. You'll know right away if utilization increases or if error volume becomes suddenly higher. Continuous monitoring for you means ongoing oversight, and your TPAs performance will improve when they know you're in the loop. Expectations today for all forms of management are increasing, and you'll do your job better when you're monitoring.