Recently Healthcare Horizons completed an annual audit for a long-term client.  The client’s contract with its third-party administrator (TPA) strictly limits audits to random sample audits, thereby not allowing comprehensive audits.  In performing prior audits, it was apparent that the TPA was erroneously paying certain claims, but such claims were not selected via the random … Read more

In recent months, we noted a record finding for a single claim recovery of over $1.7 million dollars for a client and a systemic error involving thousands of claims totaling over seven million dollars in recovery for a client.  We all recognize that news shows focus on big stories rather than daily routine events to … Read more

This month’s Lost Benjamins Award highlights the importance of persistence and perseverance. During the performance of a comprehensive audit for a large, self-insured employer, Healthcare Horizons™ noted claim charges based on a 22% fee rate that appeared to have no explanatory basis. It initially appeared to be a fee charged by the employer’s third-party administrator … Read more

Healthcare Horizons™ began the Lost Benjamins Award to highlight the importance of self-insured employers having annual audits of their paid medical claims. We share some of our audit findings to show how much money companies may be losing simply by not looking closely at their claims data. Some errors may appear to be small dollar … Read more

Lost Benajmins Award Nominee: June 2023 In the past, we have presented Lost Benjamins Nominees as stand-alone examples of specific cases we have come across in our audits. This month, we turn to a pair of articles that demonstrate how widespread some of these errors have become across the country in companies we audit (and … Read more

Lost Benajmins Award Nominee: May 2023   After many years of developing medical edits to identify excessive charges for medical professionals, facilities, devices, implants and other medical services, many third-party administrators (TPAs) report very high accuracy in paying claims.  However, Healthcare Horizons continues to find extraordinarily large overpayments that are undetected by TPA’s adjudication software … Read more

Lost Benajmins Award Nominee: April 2023   To help keep healthcare costs in check, most insurance benefits plans have tiered coverage. Each plan defines rates for in-network versus out-of-network non-emergency care. This month’s Lost Benjamins Award explains how an employer would have lost nearly $100,000 from inaccurately paid claims if a comprehensive claims audit had … Read more

Missed Opportunity Recently Healthcare Horizons™ personnel identified a large overpayment of a medical claim by a client’s third-party administrator (TPA) that was quite surprising.  If you have followed our Lost Benjamin Awards, you know that our finding large overpayments is quite common because we audit 100% of our clients’ medical claims on most engagements.  What … Read more

Infusion Billing Confusion Finding the error makes things make sense and saves money Healthcare Horizons recently saved a self-insured employer over $500,000 related to a drug infusion claim.  The third-party administrator (TPA) paid the claim based upon a percentage of charges from the provider, as it had paid for the infusion service visit.  However, the … Read more

Covid Billing Changes Create Chaos Remember when Covid testing was covered for everyone – and then it wasn’t? As the severity of the Covid-19 pandemic increased the demand for healthcare services and products, every major third-party administrator (TPA), along with self-insured employer clients, modified procedures for COVID-related services, including testing.  These modifications impacted many provider … Read more