Sometimes self-insured employers are unaware of the fine print buried in the service agreements they sign with their third-party administrators (TPAs). That fine print can leave them vulnerable to costly mistakes. Recently, Healthcare Horizons worked with a local county government. The contract limited the county to conducting only random sample audits of their healthcare claims. Although we know a comprehensive audit process ensures the best return of recovered dollars for our clients, we got to work and crossed our fingers.
Due to the audit process limitations, we conducted a random sample audit, and we got lucky by uncovering a previously hidden error. The employer’s plan did not cover non-emergency, out-of-network claims, however, the TPA paid a $50,000 claim for a planned back surgery. That claim should have been denied, and Healthcare Horizons helped the client recover the money. 
We are experts at finding errors like these and recovering them for our clients. We also offer free audit rights assessments to self-insured employers. We help our clients so they can take advantage of comprehensive audits and other benefits that come from our 100% difference, such as avoiding the two-year no-recovery clause and other limitations.
When “Close Enough” Isn’t, contact us at HHAdmin@HealthcareHorizons.com to learn how we can help with audit rights assessments.
Randy King is president of Healthcare Horizons Consulting Group, Inc., which has performed healthcare claims audits since 1999. Trusted partner. Uncompromising accuracy. Superior personal service. We have recovered millions of dollars for some of the world’s largest employers and audited claims by all national third-party administrators.
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