Lately, there's been legal action in the news as a large employer that self-funds its benefit plans has taken a third-party administrator (TPA) to court. Finding from medical claim auditing will likely play a role in the dispute over too-high plan costs. Health plans experience cash outflow when claims are paid, and it's why processing them accurately means everything. It's an outlier in business to have one company paying another company's bills – but it's what happens when a TPA handles claim administration. Following up with a claim audit gives valuable insight into any irregularities detected.
One of the most exciting developments in the claim auditing field has been the development of boutique firms that specialize. They are in the trenches daily auditing every TPA in the business, and their highly developed knowledge and processes quickly spot errors. The most significant opportunities will always be in systemic error patterns that are caught and corrected. But mistakes happen just as easily on individual claims, and flagging all of them presents recovery opportunities. Some plan sponsors may handle the recovery requests directly, but it often falls to other third parties.
It's also worth noting that medical billing and coding are complex endeavors with many opportunities for errors. In the rush of providing treatment, incorrect codes can be entered or services duplicated – double billing happens more than most people realize. While the claim payment system may spot many of these irregularities, it's inevitable that some slip through the cracks. Experienced auditors find them, most often immediately and sometimes with later scrutiny. Even though most systems are electronic, human error still exists. Each year as things become more complex, auditors improve.
Healthcare claims auditing requires a sophisticated understanding of medical billing and financial considerations. Producing accurate and detailed reports requires merging the two and correcting audit setups. There are constants for all claim audits, but every plan has one-of-a-kind provisions that must be followed. When they are carefully included and the data reported in actionable reports, the value of the audit increases exponentially. The purpose is to take a magnifying glass to the details and give an independent assessment of the findings. Financial opportunities are continually significant.
Company Name- TFG Partners
Address- 437 Grant St #1020, Pittsburgh, PA 15219
Contact Number: (412)-281-2228
