Better Software Powers Accurate Claim Auditing

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Company Medical and Benefit Claims Auditing | TFG Partners

Not all medical claim auditors are alike, and if you're a large employer sponsoring your company's health plan, you want the most accurate firm. The best claim auditors have perfected proprietary software that powers their audits. All audits are about getting the details right and scrutinizing every data point on every claim. When electronic reviews are highly accurate, it saves time and money, not to mention flagging more errors and irregularities. Improved accuracy brought audits from a regulatory compliance function to a management tool. Now plan sponsors audit and monitor claim processing routinely.

One of the most significant opportunities in claim auditing is to make processing system improvements that eliminate groups of errors – for large plans with substantial numbers, the opportunities are enormous. Auditors with sophisticated proprietary software can group and categorize irregularities they flag, making it automatic to identify error patterns. What used to require hours of human review now occurs in seconds with no extra effort required. The electronic check needs to be advanced because claims and payments are complicated and detailed. When it is, the process becomes faster and more accurate.

The continuous improvements and updates build on a foundation established during the 1990s when auditors began to review every claim (100-percent) and moved away from random sampling. It ushered in a new era in which large employers with self-funded plans started to understand the potential of frequent audits or even continuous monitoring of their plans. As claims are double-checked shortly after they are paid, recovery of overpayments and errors is quicker and smoother. It changes the system from sampling and makes it a clear snapshot of every dollar spent. The level of accountability skyrocketed.

Many top audit firms specializing in claim reviews have unique expertise, including managers from large health insurance carriers. They devoted their careers to claim processing and to understand the nuances. As a result, they can build and refine systems that can be tough for generalist firms to match. Part of any electronic review means overlaying the processing system and checking it for details. When it happens with 100-percent claims, you receive a report of unmatched detail and accuracy that is easy to read, understand, and has actionable data.

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