COVID CASE OVERLOAD
In an example of why two sets of eyes are always better than one, we recently reviewed a series of claims that a company’s TPA flagged as being incorrectly billed. However, when we reviewed the data for the entire audit period, we found a systemic problem. MORE THAN 22,000 Covid-19 claims were submitted by one provider and one clinic instead of the claims being submitted by each individual location and physician that performed the service.
Why does this matter?
During the Covid-19 pandemic, funds were allocated for any testing or treatment done for the disease. For instance, if someone saw a physician for what they assumed was bronchitis, but then tested positive for Covid, specific pandemic funds were allocated to the provider for this care, above what they would have received for treating bronchitis. The more cases that are incorrectly billed, the more money that is allocated from these funds, potentially taking money away from others owed relief dollars.
In this case, if all 22,000+ cases in this billing period were performed at the same billed clinic, there would have been more than 239 visits per day, every day. Since the billing issue began, that provider has been paid for more than 64,000 claims! This would not be possible for the same location. Because of inaccurately attributing services to another clinic instead of the actual clinic providing the care, one location was receiving monies owed to someone else.
Financial impact
We estimate that more than $2.6 million was incorrectly paid to this one provider through the one billing clinic and there is no concrete way to know how absurd the overpayment could have gotten if the systemic error was not identified and corrected. Audits matter!
Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through its 100% Difference model, recovering millions of dollars for clients’ bottom lines with uncompromising ethics and accuracy. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for some of the world’s largest self-insured employers, involving all national payers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for employers.