In business, many things are cyclical, and the post-pandemic era may see employer-funded health plans reasserting more control over claim payments. They're working with healthcare auditing companies to double-check claim payments made on their behalf by third-party processors. With nearly all self-funded plans outsourcing their claim processing, it's natural there would be an oversight. But lately, there have been lawsuits by large plan sponsors against their processors alleging irregularities. The promise is to pay claims fairly and accurately with very low error rates. Only auditing can independently verify it happens. 

There is value in outsourcing because large plans have provider networks, negotiated rates, and processing infrastructure that can drive down costs. But it all depends on whether every part of the process functions correctly and optimally. Given the complexity of medical billing, hundreds, if not thousands, of factors are in play daily. For large plans with high claim volume, the opportunity for errors is significant, and relying on processors to identify and self-report them creates risk. Specialist auditors who are highly skilled in reviewing claim payments can quickly verify the accuracy.

Getting it right with claim payments in one year doesn't always equate to similar accuracy in the next. It's because medical services and medicines are always changing. New products are introduced, and some prices go down as others skyrocket. It's a dynamic situation in which everyone involved must continually review their methods and costs. For corporate employers with shareholders and analysts to answer to, staying on budget is essential. When there are fluctuations and overages, explaining them in detail is crucial. Reports from claim auditors confirm the needed information.  

Anyone who studies the field knows today's "best practices" of checking 100 percent of claims is a vast improvement over the original random sampling system. Thanks to the never-ending enhancements in software and systems, new levels of audit accuracy are possible in less time and for reasonable prices. It has taken a regulatory and compliance function and turned it into a management opportunity. Companies self-funding benefits plans have considerable financial exposure, and running oversight gives them more control and peace of mind. Outsourcing claim processing is okay with double-checking.

Company Name - TFG Partners

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

Contact Number : (412)-281-2228