100-Percent Claim Auditing is an Essential Management Tool

TFG Partners is a healthcare claims audit and monitoring firm that has been leading the industry for nearly 30 years.


Large and mid-size corporations with self-funded medical and other benefit plans face claim payments that aren't transparent. It's why highly accurate claim audits and continuous monitoring of claims paid are so essential to the bottom line and ensure employee plan members receive the services they are promised. Spending on medical costs is one of the most significant corporate expenses. But unlike other high-cost areas, it is a routine expense that builds no infrastructure nor equity. With careful auditing and monitoring of claims, there are also opportunities to stress prevention to employee plan members.

Today, claim auditing is increasingly recognized as a strategic management tool that is beneficial on multiple levels. There was a time when many plans did the bare minimum and had themselves audited only to comply with ERISA and other government regulations. Today's more effective benefit plan managers schedule sophisticated audits covering 100-percent of claims paid. They want to fix systemic errors and recover overpayments or any payments made in error. Claim administrators make many promises about accuracy, but they all make mistakes that cost money and don't help employees.

Excellent audits help companies recover more than the cost of the service paid in error. They lead to plan improvements and put money back into budgets. Neatly always, the sums recovered by 100-percent audits and continuous monitoring far exceed the auditor's service fees. Since the 1990s, leading medical and pharmacy benefit auditors have reviewed 100-percent of claims and improved their methods and software. There are differences among auditing firms, and only those with superior techniques and technology find the most error; it takes more than reviewing 100-percent of claims paid.

With the never-ending increases in health care costs in the United States, continuous claim monitoring after an audit is in increasing use. It utilizes much of the same software as an audit and reviews all claims paid in nearly real-time. Errors and irregularities show up immediately and can be addressed when they are small and more limited problems. It's beneficial for employee plan members who have high deductible plans, and with many administrators, you can require fixes right away. Having the right information, lets plan managers recover overpayments to control costs and serve members better.