1. Business

Technology in Claim Auditing Today

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Medical and prescription medication costs increase yearly, and the pressure on health plans is enormous. Large insurance carriers work relentlessly to contain spending, and self-funded plans rely on a healthcare audit to double-check claim payments. More advanced technology and systems powering today's auditing are responsible for many improvements, chiefly accuracy. Small details are reviewed on every claim paid and reported when irregularities are suspected. They provide considerable opportunity to improve claim administration. It's beneficial for cost containment and member service.

Much of the technological advance has come from specialist firms in the claim auditing field. They've spent every day in the trenches and continuously improved their systems. You're seeing evidence of the value of those reviews as some large employer-sponsored plans take on their claim administrators. Some are even going to court alleging overcharging and other lax practices that have cost sponsors millions. Audit reports likely played a role in those realizations and, later, the legal claims. There is no substitute for skillful oversight. When one company pays another's bills, it's a delicate situation.

Specialty claim audit firms also typically have executives and staff with experience in medical billing, perhaps having worked with a large insurer. Given the situation's complexity, it goes beyond the numbers-driven knowledge required for financial audits related to tax and performance. Medical claims have hundreds of data points and the necessary coding to describe services. They provide countless possibilities for errors that only someone with the proper knowledge can spot. It's also why these firms have built more effective software; their systems are among the most advanced ever. 

If anything shined a spotlight on the value of medical and pharmacy claims auditing, it was the coronavirus pandemic. Higher utilization, novel tests, and treatments brought a nearly out-of-control situation that heavily impacted everyone. In the aftermath, auditors helped everyone in the equation review the situation and work to make improvements. Since then, the number of employer-funded plans monitoring their claims payments continuously has increased. It means keeping the audit software running all year and reporting the findings monthly. It's an excellent way to keep tabs on cost trends.

Company Name: TFG Partners, LLC

Contact Number: 412-281-2228

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


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