<link href="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/js/bootstrap.min.js"></script> <script src="//cdnjs.cloudflare.com/ajax/libs/jquery/3.2.1/jquery.min.js"></script> <!------ Include the above in your HEAD tag ----------> <div class="container"> <div class="row"> <h2>Claim Audits Save Health Plans Money</h2> </div> </div> <p>Large employers’ self-funded medical and pharmacy benefit plans are designed to deliver top-tier health care to employees and their families. These plans involve substantial expenses, with <b><a href="https://www.tfgpartners.com/medical-claim-audits">medical claims auditors</a></b> playing a key role in cost management. Enhanced accuracy in claims auditing and ongoing monitoring can significantly affect financial outcomes. Fortunately, advancements in software now boost audit precision and enable review of every paid claim. Even when claims processing is outsourced, these tools empower in-house plan managers to maintain active and detailed oversight.</p> <p>Specialized audit firms focus on reviewing claim payments and often employ staff with deep healthcare backgrounds. Their industry experience enables them to continually enhance both their software and review processes—using a mix of electronic and manual checks—to achieve impressive accuracy rates. Leading organizations partner with dedicated claim auditors rather than generalists who cover multiple fields. The day-to-day expertise of those devoted to claim payment audits is vital. Their efforts reduce expenses while consistently improving member service and meeting fiduciary responsibilities.</p> <p>Outsourcing claim payments to third-party administrators (TPAs), frequently large health plans, has become increasingly common. While TPAs offer substantial expertise, errors still occur and can persist unless uncovered by an independent audit. With rising healthcare and prescription costs and ongoing pressure to be profitable, companies must closely manage their benefit plans. This necessity prompted a shift toward auditing all claims, not just random samples. Once software made full audits feasible, the specialist audit firms and their largest plan clients began verifying 100 percent of paid claims.</p> <p>A recent advancement in this critical area is the adoption of continuous claim payment monitoring. Using audit software, it operates in near real-time. Errors that once went unnoticed until periodic audits—and therefore went unaddressed—are detected promptly. When providers raise prices or alter their billing practices, it can have a major effect. Early detection enables timely inquiries and negotiations that may prevent sudden cost increases. Plan members, particularly those with high deductibles, also gain from oversight. In short, accuracy yields wide-ranging advantages for every plan.</p>