Drowning in an Overpaid IV Claim

A classic case of This Or That?

  Water Hose OR IV? 

Last month Healthcare Horizons’ personnel submitted an audit finding to a client’s third-party administrator (TPA) to review the resolution of a claim containing an obvious error. The claim was submitted for 1,000 units of J7120, delivered intravenously in one hour in an office setting. Unfortunately, the TPA had paid the claim as submitted. Based on our calculations 1,000 units would be over 250 gallons of intravenous fluids – a person would be drowning from that much IV! The TPA’s quantity edits obviously failed to identify the error.

We submitted the finding to the TPA and received the following response: “Based on the outreach and response from the provider, the units were filed correctly.” Most unfortunately, such TPA responses are not uncommon when we submit our findings. That is why you want an auditor who will diligently document findings and subsequent follow-up. As expected, after the TPA’s initial response was challenged because of the obvious error in the claim, our client received credit for the excess payment made by the TPA.

Payment errors such as this caused Healthcare Horizons to initiate the Lost Benjamins Award.  We hope sharing such stories raises awareness of the importance of self-insured employers having annual comprehensive audits performed by experts on 100% of their medical claims.

Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through its 100% Difference model, and 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 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.