How Claim Audits Can be More Effective

In the past, self-funded corporate health plans were audited using periodic random-sample methods. While this approach satisfied regulatory requirements and was standard practice, it had major limitations. In the 1990s, however, a notable change occurred as innovative companies began leveraging software developments to review 100 percent of claims for medical and PBM audits. This extensive approach set a new industry standard, offering far greater accuracy and insight. Early adopters promptly gained a competitive advantage, inspiring extensive adoption of these more thorough auditing methods.

Under the old random-sample model, processing errors and repeated overpayments could go undetected for long periods, sometimes growing into major issues before anyone noticed. This often resulted in difficult negotiations with providers to recoup erroneous payments. The adoption of 100 percent claim reviews significantly modified this situation. Now, audits generate concrete data that supports better negotiations with providers and indicates to health carriers that their claims processing is under scrutiny. This improved oversight increased accuracy throughout the claims process.

Today, many organizations are taking their auditing efforts further by implementing continuous monitoring services for claim payments. Real-time oversight makes it much more difficult for errors or irregularities to persist and escalate. By detecting faults early—while the number of affected members and financial impact are still small—companies can resolve them quickly and stop similar mistakes from recurring. The cost of ongoing monitoring is typically much less than the savings generated by catching and correcting mistakes early, rendering it a wise investment that benefits budgets.

The growing adoption of ongoing claim monitoring underscores its value. While processors may promise accuracy, independent oversight continues essential. The knowledge claims are being monitored often leads to higher service quality from carriers. If errors do occur, data from ongoing audits offer a strong basis for resolving issues and making improvements. For managers of self-funded plans, ongoing monitoring means being able to answer questions from finance teams about costs or anomalies. Immediate access to reliable audit data enables quick, informed responses and supports management.

Every benefit plan for prescription drugs are unique and need to be followed closely. While TPAs easily promise to be detail-oriented in their work, only an independent prescription claim auditing company like TFG Partners can confirm it. For example, one of the most common ways for a plan to go off track is when scripts are written and claims paid for name-brand medicines when generics are available. It’s an easy catch for auditors and one that can save significant sums of money while making no difference in the outcomes for plan members – high-quality generics are widely accepted.

Also, not enough can be said about the value of conducting an Rx audit for prescription plan claims. Furthermore, continuous monitoring following a claims audit can help members, especially those in high-deductible plans. Keeping a close watch for over-payments, double-payments, and other errors benefits members as well as the plan sponsor. When plans are not audited and monitored, it’s much more likely that claim administration is accurate. A well-run plan is the objective of every company, and in-house managers know the time it can take to recover payments made in error. It’s always a better approach to manage and audit closely and keep claim payments on track.