In this two-part series, we will examine a few of the top categories of claims payment errors. Missing these common errors means that self-insured employers are leaving possibly hundreds of thousands of dollars on the table every year.Rather than asking your employees to contribute more in terms of higher premiums or reducing their benefits, self-insured employers should ensure that their TPA is processing and paying healthcare claims correctly.
It’s our job at Healthcare Horizons to take a closer look and return those dollars to the bottom line.
Top categories of claims payment errors
- Duplicate payments
- Eligibility
- Coordination of benefits
- Medical edits
- Inpatient readmissions
- Multiple procedure reductions
- Out of network reimbursement
- Benefit maximums
- Benefit exclusions
Duplicate Payments
While most clients would expect duplicate claims to be rare, they are actually quite common in healthcare claims payments and usually result in recoveries on every project conducted by Healthcare Horizons. A recent audit turned up nearly $50,000 paid in error in just 10 duplicate paid claims.
Eligibility
It is important to validate coverage on the service date. Employer groups often submit retroactive terminations to the administrator, resulting in an opportunity for overpayments unless the administrator has a process in place to identify and recover these claims. In addition to claims paid after the termination date, Healthcare Horizons identifies claims paid during a gap in coverage and claims paid without an eligibility record on file.
Multiple Procedure Reductions
When multiple services are performed in the same session, secondary procedures are priced at a reduced percentage (usually 50 percent) of the normal contract rate. This automatic reduction accounts for savings gained by only having to prepare a patient once for multiple procedures. We flag claims that may have missed this standard discount by reviewing the secondary procedure allowance.
We often hear the words, “Our TPA has us covered,” and while most TPAs do a good job of processing claims, it is our business to conduct thorough, 100% Difference annual audits that return money to our clients. People make mistakes. Healthcare Horizons is committed to finding every claim and every possible dollar for our clients.
The Difference is in Knowing.
To learn more about our approach to healthcare claims auditing or out-of-network provider fee negotiation services, visit Healthcare Horizons, or reach out to us at hhadmin@healthcarehorizons.com.
Randy King is president of Healthcare Horizons Consulting Group, Inc. The company is one of the nation’s leading healthcare claims auditing firms, focused exclusively on self-insured employers since 1999. Healthcare Horizons has recovered millions of dollars for its clients through auditing and air ambulance negotiations for some of the world’s largest employers.