What is Full-Service Medical Claims Auditing?

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


In the medical claims auditing industry, a full-service approach dramatically improves the value of an audit and helps it add value for many years to come. The most effective claims auditors do far more than run an audit, report the finding, and call it a day. Instead, they go out of their way to make sure their work adds value. The most accurate audit should serve only as of the beginning of the process, and when complete, it should yield many actionable results. Excellent claims auditing goes well beyond budget neutrality and produces savings that are far more than the original cost of the audit.

Often full-service auditing produces results in four areas. The second one after the audit itself is advice. In the advisory component, the auditor consults with company management and the claims administrator about areas for improvement. Avoiding future errors can make a significant improvement both financially and also in better serving the employees who are recipients. Patterns and categories of mistakes that repeat often can greatly diminish plan performance and contribute to escalating costs. Making sure to avoid similar errors in the future improves claims administration efficiency.

Recovering the funds lost to payments made in error is the third leg of full-service benefits plan auditing. It can lead to considerable cost savings and return dollars to the plan for the benefit of the company and its employees. Given the strain that skyrocketing medical costs have put on self-funded plans, recovering lost dollars is vital. An audit that covers 100-percent of claims paid by a plan also makes a meaningful improvement in detecting overpayments that can be recovered. Full-service auditors are budget neutral and better because they follow through to assist with recovery.

Advocacy is the fourth and final component. It means working with claims administrators and possibly even providers to protect a company's interests. Claims are paid in a sincere effort to help employees and provide them with care, therefore conserving plan dollars and accurately processing claims is essential. When errors occur at the administrator level, having a strong advocate to suggest improvements is necessary. Better still is to suggest strategies for more accurate processing. Over time the improvements brought about by auditor-advocates will optimize claims administration.