EP433: The Mystery of the Weekly Claims Wire: What Are Plan Sponsors Actually Paying For Each Week? With Justin Leader
Relentless Health Value
00:00
Navigating Audits and Claims in Healthcare
This chapter explores the challenges of conducting audits within health plans, highlighting conflicts of interest when the same organization manages both administration and auditing. It examines the role of Third Party Administrators (TPAs) in claims processing, emphasizing the need for accurate metrics and oversight due to the reliance on auto adjudication. Additionally, the chapter discusses the implications of spread pricing and the necessity of transparency in claims costs to avoid long-term financial pitfalls.
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