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