Lost Benjamins Award: February 2022 Nominee for Most Absurd Healthcare Claim Not counting some kinds of skin cancer, colorectal cancer is the third most common cancer in men and women. It is the third leading cause of cancer-related deaths in the United States. Colonoscopies help identify and remove polyps that can turn … Read more
Lost Benjamins Award: January 2022 Nominee for Most Absurd Healthcare Claim Man Glows After Hundreds of X-Rays on Same Day No, this didn’t really happen. But absurd healthcare claims appear almost everywhere. If this absurd healthcare claim was actually true, this patient would have been out thousands of dollars and been exposed to an extremely … Read more
Healthcare Horizons™ identified an issue for a client regarding the administration of a skilled nursing benefit maximum. The overpayments were due to a combination of inconsistent billing by the facilities and manual processing by the claims administrator. After the review by Healthcare Horizons™, the client recovered more than $1 million in overpayments, and a root-cause … Read more
One of our clients had a member arrive at the emergency room with a potential shoulder fracture; the patient was provided an X-ray examination and an arm sling. The hospital incorrectly billed for 1,400 arm slings, and the claim administrator paid the claim at $150,000. Healthcare Horizons™ identified the error, and once the claim was … Read more
Healthcare Horizons™ identified an instance for a client in which a surgical implant was billed incorrectly at $777,000 versus $77,000. As the reimbursement was based on a percentage of the charges, the billed charge amount had a significant effect on the final payment, resulting in an overpayment of $300,000. Initially, the claims administrator responded that … Read more
A recent trend to reduce healthcare expenses is for plan designs to limit out-of-network exposure. A common example is to place a maximum plan allowed amount for out-of-network based on a percent of the Medicare fee schedule rate. On a recent audit for a modest-sized media company, Healthcare Horizons™ found that all out-of-network claims were … Read more
By rule, Medicare is generally primary for COBRA participants who are age 65 and older. In other words, employers only have secondary liability for healthcare claims. A recent audit revealed a large volume of claims incorrectly paid as primary by our client on this issue. As it turned out, the TPA was relying solely on … Read more