The big money but generally quiet world of medical claim payments is suddenly making news as large self-funded plans are suing their claim administrators – which are well-known health insurers. It is expected to encourage more self-funded plans to run a healthcare audit to double-check their payments. Generally speaking, in business, it is a peculiar scenario when one company is hired to pay another one's bills, but it works that way with health and prescription claims. Years ago, come self-insured large employers might have paid claims directly, but outsourcing has become the norm in the industry.

Outside claims administrators in the form of large health carriers bring their provider networks, infrastructure, and expertise to the table. They are hired with promises to manage and control the care paid for by self-funded plans. They also commonly promise to keep error rates ultra-low in the single digits. Auditing is a plan sponsor's best defense to verify promises are being kept, and claim payments are carefully managed. Even for well-functioning plans, there may be areas to question based on an auditor's findings which point to the value of the audit. The factual data from audits is helpful.

Recovering overpayments is a topic of great interest for health and pharmacy benefit plan sponsors. If mistakes are made, is that money lost forever, or can it be repaid? Recovery opportunities point to the value of timeliness in claim auditing. Reviewing payments more promptly can uncover errors sooner and correct them to prevent million-dollar problems. Finding experience claim payment reviewers also matters. Today there are firms specializing in the field, and they bring experience in auditing and medical billing. For them, knowing where to double-check is second nature.

If you manage a self-funded plan and switch to a new processor, regardless of the type of benefit program (medical, pharmacy, etc.), schedule an implementation audit. The ideal time is generally agreed to be after 90 days. At that point, enough claims have been paid to get a handle on accuracy and areas where system fixes are needed. Every pan has hundreds, if not thousands, of unique provisions that need to be in the system for claim payments. The closer the payments stay to agreed-on guidelines and requirements, the better members are served. It also helps control costs in the short and long term.

Company Name- TFG Partners

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

Contact Number: (412)-281-2228