JGI Blog

Out-of-network charges run amok

JGI found in a recent audit that our client’s TPA was paying significantly more for out-of-network claims than the plan’s benefit allowed. The TPA was running claims through a rental network, usually for small percentage of charge discounts, but was ignoring the UCR limits of the plan. The result was...

Sharing

In 2015, JGI was proud to donate a portion of our revenues to Siloam Family Health Center and Faith Family Medical Center. We set a goal from the founding of our company to give annually to causes selected by our employees. For JGI, this feels like the right thing for...

Claims Audits Are NOT a Software Solution

I have been asked many times in my 16-year career in claims auditing about the software that we utilize to perform our work. The fact is that it is easier to understand our job as a black box program that spits out errors than one which requires constant time, attention...

Will I need another audit if the TPA fixes everything from the first one?

Operational improvements at the TPA are a frequently overblown promise in the claims audit market. We commonly see proposals that promise that the claims audit vendor will ensure that the TPA fixes everything that caused errors. The first problem with this, of course, is that the audit firm has no...

Evaluating Claims Audit Vendors

Shopping for a claims audit is difficult, given the limited exposure to claims audits topics for most employers. Some common issues to pursue in evaluating proposals include: What is the scope of your auditing process? Claim audit firms couch their actual scope in lots of verbose language, but the important...

Why Do I Need a Claims Audit?

The healthcare industry is a sloppy one and costs are constantly on the rise. Industry studies show that overpayments are 1-3% of total expenses, not including fraud. Self-insured employer healthcare plans are complicated. They often include highly customized benefits. Many TPAs have difficulty programming these custom plans and often rely...

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