March 2024
Lost Benajmins Award Nominee
Don’t Pay a Transfer Tax!
Healthcare Horizons personnel continue to find instances of providers being paid full case rates for hospital inpatient admissions, despite patients waiting only a few hours in the original facility before a transfer to another facility for care. As a result, the self-insured employer and patient are incurring full payment responsibilities for two “inpatient” stays.
The frequency of these findings and the inadequate explanations received for such payments are an ongoing issue. As with any significant finding, we always attempt to determine the root cause. Having evaluated this issue for multiple clients, we concluded most electronic claims adjudication systems are unable to identify these claims. Since these types of incorrect claims can’t be found by the system, they aren’t identified for appropriate reimbursement to providers according to contract terms. As a result, such claims are paid at full case rates –TWICE. This occurs even when hospital provider agreements include defined terms for paying the initial provider at reduced rates.
Such patient encounters are not infrequent, so it is quite troubling to realize many claims adjudication platforms aren’t sophisticated enough to electronically identify and appropriately resolve such claims according to provider agreement terms. This is another excellent example of the importance of independent, comprehensive annual audits of paid medical claims by highly qualified auditors specializing in such audits.