As we reflect on the past year, we are proud to share some of Healthcare Horizons’ most impactful audit findings of 2024. Our commitment to thorough, comprehensive audits using our 100% method, has resulted in significant savings and policy changes that benefit our clients and the broader self-insured community. Here are the highlights:
- Lack of Clarity in Language, Initiating Change in Policy
During a comprehensive medical claims audit for a large, self-insured government employer, we discovered a significant lack of clarity in the readmission policy language of a major third-party administrator (TPA). This ambiguous language could potentially allow all types of readmissions to be eligible for authorization review, leading to unnecessary payments.
Outcome: This discovery prompted the TPA to revise its policy language, resulting in clear limitations on payment authorizations. The estimated impact is millions of dollars in future savings on readmission payments for our government client and other self-insured employers. This finding highlights the importance of regular, comprehensive audits by qualified firms to uncover and address costly oversights, ultimately reducing healthcare costs for employers and employees.
- Largest Single Claim Overpayment Recovery in our History
In 2024, we reported the largest single claim overpayment recovery in our history, totaling over $1.7 million. This recovery was discovered due to our meticulous audit processes that identified and rectified the overpayment, demonstrating our dedication to ensuring our clients do not pay unnecessary expenses.
Outcome: This monumental recovery not only provided immediate financial relief for our client, but also highlighted the value of comprehensive audits in identifying and correcting billing discrepancies.
- Duplicate Billing for Vaccines
Our audit team identified medical claims from a provider that billed vaccine medications twice—once by the physician and once by the administering outpatient facility. Initially, the TPA responded that the claims were paid correctly. However, our team pointed out that patients were being billed twice for the same vaccination during the same visit, leading to double payments.
Outcome: The TPA recognized and corrected the error and the provider was placed under compliance review. Again, this finding underscores the importance of detailed audit reviews to ensure that clients are not overcharged.
- Overpayment for Hospital Inpatient Admissions
We uncovered instances where providers were paid full day rates for hospital inpatient admissions, despite patients waiting only a few hours in the original facility before being transferred to another facility for care. This practice resulted in overpayments that could have been avoided.
Outcome: By identifying these overpayments, we helped our clients recover funds and prompted a review of case rate payment practices. Again highlighting the need for vigilant audits to ensure accurate billing and appropriate payment practices.
Full Audit, Full Recoveries
These top findings from 2024 demonstrate the critical role of 100% comprehensive audits in uncovering and addressing costly oversights in healthcare claims to help keep your healthcare costs at a minimum.
At Healthcare Horizons, we are committed to helping our clients achieve significant savings and improve their financial health through meticulous audit processes. We strongly encourage all large, self-insured employers to engage highly qualified audit firms to perform annual medical claims audits, as these efforts not only benefit individual employers but also contribute to overall reductions in healthcare costs.
By sharing these insights, we hope to underscore the value of regular audits and encourage proactive measures to ensure accurate and fair healthcare billing practices. If you have any questions or would like to learn more about our audit services, reach out today to get a conversation going!
Here’s to a successful and financially healthy year ahead!