Identifying the Unexplainable in Health Insurance Claims

There are plenty of things to make us go “hmmm,” but health insurance payments shouldn’t be one of them! Our job, every day, is to identify mistakes in healthcare claims payments and occasionally we run across a case where there just doesn’t seem to be a logical explanation for an overpayment. In 99% of these unexplainable, head-scratching cases, they are one-off processing errors.

How Do Unexplainable Mistakes Happen?

Perhaps you’ve heard the expression, “garbage in, garbage out.” And guess what? Everyone makes mistakes. When we see overpayments where there doesn’t appear to be logical explanations, the most likely reason is human error. These typically show themselves in two areas.

• Coding errors: Medical billing codes are used to describe the services provided to a patient. These codes are complex and can change frequently. Even small mistakes in coding can lead to inaccurate payments. These can be entered incorrectly due to lack of knowledge about a procedure or unfamiliarity with a system.
• Data entry errors: These errors include the wrong patient information, incorrect dates of service or incorrect billing amounts. Sometimes a data entry error is simply a slip of the fingers. Think of when you’re typing an email or texting. When you’re quickly moving, you often won’t realize you had a typo before you hit send.

Getting Reimbursed from the Typo

Healthcare Horizons’ comprehensive, “every claim,” review process makes us successful at identifying these one-off errors. This approach yields improved results because we identify both isolated and systemic errors and assign actual dollar impact to those errors, helping our clients correct the issue and recover the overpaid dollars. By going to great lengths to ensure that our medical audits are as thorough and accurate as possible, Healthcare Horizons has been able to recover millions of dollars in overpayments for our clients, as well as ensure long-term savings by correcting root-cause issues.

For a great example of a strange error, read our latest Lost Benjamins story! 

Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through our 100% Difference model and recovering millions of dollars for clients’ bottom lines while upholding the highest ethical standards. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for some of the world’s largest self-insured employers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for our customers.