Medical Claim Auditing Services

We Pioneered the Full-Service Approach and Lead the Industry in ROI.

TFG Partners Performs 100% Medical Claim Audits

Medical claim auditing reviews the payments a given health care plan has made to providers on behalf of its members during a previous year or other defined amount of time. They are most commonly conducted by self-funded medical plans required to audit themselves first by government regulations and now because auditing is an excellent plan management tool. Self-funded health care plans are typically sponsored by large employers, both corporate and nonprofit. Medical claims auditing was conducted initially by random sample, and today most of the best claim auditors review every payment.

Self-funded health plan claim auditing has become more frequent as plans increasingly outsource their payment infrastructure to third-party administrators (TPAs). The TPAs are typically large managed care plans with extensive provider networks (doctors, specialists, hospitals, outpatient surgery centers, etc.) that can also be used for the members of a self-funded plan. A claims audit provides in-house staff at a large employer with meaningful oversight of their medical claim payments. While TPAs commonly make accuracy and performance guarantees, the only way to confirm the actual results is with an audit.

How the Medical Claims Auditing Process Works

Step #1: Reviewing Medical Claims

Intensive medical claims plan document review
Confirm the intent of medical claims
Clarification of claims not defined
Review of administrator-imposed audit and recovery limitations
Customization of specific claims’ plan design
Support for additional custom review needs, by request

Step #2: Audit and Analysis

More accurate and actionable claim audit results
A comprehensive overview of all potential overpayments, regardless of a plan’s attributes
Deeper insight into why errors have occurred and what will prevent them in the future
Objective and fact-based assessment of administrator performance
Meticulous and tactful assistance in bringing about process improvements

Step #3: Advice

Better, more accurate medical claims adjudication
Detailed compliance with ERISA and Sarbanes-Oxley
Systematic/plan-wide error prevention

Step #4: Recovery

We have facilitated the recovery of many millions of dollars
The dollars are refunded directly to our clients’ plans

How Do Medical Claim Audits Work?

The goal of the best medical bill auditing service is to work independently, review claims, and report results as independently as possible – which means very little time is required from a self-funded plan’s in-house staff. A full-service audit with four parts is typically the most effective and begins with reviewing the plan’s benefits. Step two is the audit and analysis of the results. The third and fourth steps are advice on improvements to claim processing and recovery. The funds recovered are from over-payments, claims paid in error, and fraud and abuse. Better audit firms always include following through to recovery.

Advances in technology have made the 100-percent method of medical claims auditing the gold standard for accuracy and return on investment (ROI). It’s superior to random-sample audits and can produce exponentially more accurate results and lead to the recovery of more funds. When every claim is reviewed, many more error patterns and individual mistakes are flagged. The sophistication of today’s audit software also means there is no sacrifice in speed and efficiency when review all claims instead of only a few. It’s common for an audit to recover funds three to four times more than its cost.

TFG’s Medical Claim Auditing Produces an Exceptional ROI

Conventional thinking about medical claim audits is that they are budget neutral – but a TFG Partners auditing services produce a far more substantial return on investment. Our clients typically recover funds from claims paid in error that are two to three times the audit cost. Over time, the savings from process improvements are much more significant.

Medical Claim Auditing Saves Money and Improves Plan Performance

Make Systemic Improvements
Detect Fraud and Abuse
Oversight of TPAs
Recover Overpayments
Improve Service to Members
Correct Error Patterns in Processing

Do Health Care Plan Auditors Differ from Each Other?

When you interview benefits claim auditors, be aware there is a difference. It’s wise to look for independence and specialization (expertise) because they are two of the most important determiners of outstanding performance. Because many self-funded health plans are large, the scope of the work is significant enough to support firms that become specialists in auditing medical claims. They are staffed by people with deep experience in health insurance claims and who know the methods and technology that are required to audit with speed, precision, and accuracy. You’ll notice a difference. At TFG Partners, we’ve pioneered many of the advanced claim audit methods widely considered best practices today. We’re industry leaders and specialists in the field. Not many claim auditors can match the accuracy and efficiency of our work. Our list of satisfied clients spans a wide range of mid and large-size self-funded medical and other benefit plans sponsored by corporations and nonprofit entities. We were the first to develop a method to review 100-percent of claims, and any other firm doing today has followed our lead. We’re the best choice to improve your plan performance.

What’s the Best Way to Keep a Plan Performing Well?

Now you can leverage the power of sophisticated audit software in real-time. Join the many large self-funded health plans already subscribing to a continuous claim payment monitoring service. It is the strategic management tool that puts you as the in-house plan manager firmly in control. Mistakes and fraud are caught and stopped early on, and you have concrete data for oversight of your TPA. You’ll recover far more than the cost of the service, improve plan performance, and be able to lead systemic improvements to serve your members better.

What Data Security is There During an Audit?

Protecting personal information is something the claim audit industry takes seriously, and we keep in place advanced safeguards. Our security program at TFG includes both electronic and physical security at our server and office locations. We have been industry leaders for many years and are known for our attention to every detail. Our methods keep your members’ confidential data safe and secure during all phases of our work. We want our clients to have peace of mind knowing we are conscientious about security and confidentiality.

Find Out What a 100-Percent Medical Claim Audit Can Do for Your Plan

If you’ve been auditing a random sample of claims payments only to comply with regulatory requirements, it’s time you found out more about the better way to do it. TFG Partners is a leading health plan claim auditor with a long track record of saving self-funded plans millions of dollars. We’re ready to help you get your plan on track for better performance and oversight of your TPA. Your members will be served better, and you’ll control skyrocketing health care costs. The right benefit claim auditing can make a significant improvement for your plan with little time commitment from you.