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 paid incorrectly at full billed charges. In addition to an immediate return of $500,000 for historical overpayments, the TPA made systemic changes to accurately process out-of-network claims moving forward.
