Two is not always better than one
There’s an old saying that “two are better than one”. That may be true when it comes to friends, but it is definitely not true for medical claims. Even in today’s times with all of the advances in technology, duplicate medical claims still occur and sometimes at an alarming amount. During our medical claims audits, Healthcare Horizons searches extensively for duplicate claims and often finds them.
This Month’s Lost Benjamin Award Nominee
During a claims audit, a particular claim for more than $1,000,000 for payment for a surgical procedure and a hospital stay was processed by a TPA. Another claim for this particular member had previously been processed by the TPA a month earlier for over $300,000. Even though the two claims had different billing amounts, the procedure codes, member information, and dates of stay were identical. However, each claim had a different provider name and a different tax identification number (TIN).
After thoroughly investigating these claims and working with the TPA, our auditors discovered the facility which provided the services had two different TINs and that they had submitted interim and final bills for this case via their separate TIN numbers. Although the TPA should have identified this type of duplicate claim and declined it for payment, it nevertheless was processed and payment was remitted to the provider for each invoice. Had the client not engaged Healthcare Horizons to conduct a comprehensive audit with a review of 100% of the claims, these two claims would have remained as originally processed and the client would have overpaid for the member’s services by more than $1,000,000.
Billing Mistakes Happen Every Day
Billing regulations are complicated and billing processes are often complex. Billing mistakes happen every day. Duplicate claims continue to occur in almost every plan that we audit. If you are a self-insured employer, you should be engaging external firms to audit your health plan to help ensure that your members’ claims are being processed correctly and that duplicate claims are being identified and then eliminated.
Noticing and rectifying duplicate invoices will save money. Random sampling audits don’t always catch duplicate billing issues. We can help.
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.