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 ability to guarantee that the TPA fixes anything. Second and more importantly, many errors are not caused by a system programming issue but instead by either incorrect human judgments, unexpected information from the provider or member, information updated after initial payment of the claims, or some combination of all of these.
Very few errors found in a claims audit have the rather simple fix of updating programming in the system. It happens, but not most of the time. They more often require changes in operations of the TPA. Most claims payers are extremely large companies themselves. Changes in these companies are not simple procedures, and they do not happen quickly. These companies are built for scale, and navigating that scale is a very complex process.
JGI offers a realistic approach to the constraints of this market. First, we identify root causes for every error possible and push for changes in those that can be corrected. This means not simply showing that changes are needed but attempting also to isolate specific codes or claim conditions that are allowing for errors. For those issues that are not likely to be fixed by programming changes, we also encourage clients to establish ongoing routines for monitoring problem areas that are identified in the audit process. Finally, we recommend that all self-insured employers consider a regular claims audit program that includes an audit at least every other year to ensure that errors can be identified and corrected. These three pieces combined offer our clients the most realistic and thorough protections in this market.
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