The Good News in Medical Claim Auditing

Posted on 10 August, 2023 by TFGPartners

Technology has advanced in every area, and for medical claim auditors, it’s meant more thorough claim reviews faster and with less human oversight. It’s not to say that it’s entirely digital enterprise because human insight continues to create considerable value. But the power of today’s electronic claim reviews is unprecedented. The level of detail they produce is impressive as they doublecheck and analyze every claim paid. If you’re in a plan management role, you’ll receive an easy-to-read, detailed, and highly accurate report. Ask about what you need to know in the pre-audit meeting to help customize results.

Years ago, when audits relied on random samples, accuracy was far less, and while there was value, it was more about regulatory compliance. Better plan management opportunities have largely arisen because of the 100 percent method that checks each claim individually. Reporting detail to that level allows sponsors to recover overpayments and manage their plans more closely. Nearly all claim payments today are made by third-party processors. It places management of the process with a different company and increases the value of oversight.

You’ll see it in the reports you receive and their importance. Not all claim audit firms are created equal; understanding more about them is helpful. Most have proprietary software and methods that drive their processes.It’s a hybrid field combining traditional auditing fundamentals with knowledge of medical billing – which is more complex every year. It’s routine for executives in the field to have a background in claim administration that they draw on to design their systems and keep them focused on problem areas. Each plan’s unique provisions make it necessary to custom audit in each case. There are general trends by specificity matters for accuracy.

Upper management at your company will become claim auditing’s biggest boosters when they see the budget value. An audit will likely find as much as four times its price in recoverable irregularities and mistakes. It’s your choice about how and when to recover them, but when you audit often and accurately, you’ll have a better chance of recovery. Auditing long after the fact makes a recovery more complicated, and simplifying the process with timely reviews makes sense. Your plan also works more fairly and efficiently when it’s well-managed. Leveraging the potential of claim auditing is beneficial

Company Name- TFGPartners

Address: 437 Grant St #1020, Pittsburgh, PA 15219

Contact Number: (412)-281-2228