Large companies and nonprofit employers that self-fund their employee benefits put a lot on the line, especially with their medical and pharmacy claims. When they trust third parties to process their claims, they expect accuracy and fairness. Scheduling a healthcare audit is one way to conduct oversight and be sure claim processing is handled correctly. Currently, one sizeable corporate employer has filed a mega lawsuit against its medical claim processor. It alleges various parts of the agreement have not been followed, resulting in excessive costs to the plan sponsor. All eyes are on the case as it proceeds.
In many processor service agreements, there are performance guarantees written in. They give both sides a basis for their performance (and claim payment accuracy) expectations. But are those provisions closely followed? Only an outside, independent review can confirm without question that agreements are being followed and honored. How well are members being served, and are they brig treated equally? There are other questions auditors can help answer. Plan performance can be measured in many ways, each of them essential. Well-performing plans serve members better and contain claim costs.
Depending on what auditors review, they can also report on emerging trends in prices paid for medicines and services along with utilization. Without an independent review, plans are left to count on reports from claim processors. Most are accurate, but there are exceptions. The basis for the current lawsuit is the prices paid and whether the processor adequately enforced discounts and other cost reductions. The allegation is they were not, and the affected company overpaid for medical services in the millions of dollars over a multi-year period. More auditing might have caught the questioned items.
Implementation auditing is also crucial to migrating to a new claim processor. If you manage a plan and change vendors, ensure you schedule a claim review after 90 days. It’s the surest way to confirm things are being handled properly. It’s much easier to catch mistakes and repeating error patterns before they become million-dollar problems. When providers know your plan audits and questions its billing errors, it can have a beneficial effect. It’s human nature to respond to oversight and be more careful. No matter how you look at it, there are advantages to auditing claims.
Company Name – TFG Partners
Address- 437 Grant St #1020, Pittsburgh, PA 15219
Contact Number: (412)-281-2228
