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