Lost Benajmins Award Nominee: June 2023
In the past, we have presented Lost Benjamins Nominees as stand-alone examples of specific cases we have come across in our audits. This month, we turn to a pair of articles that demonstrate how widespread some of these errors have become across the country in companies we audit (and almost certainly the ones we don’t).
Ambulance Adjustments
An article regarding overpayments for certain ground and air ambulance claims over a five-year period is evidence that random sample audits often miss identifying systemic errors. It is possible that a random sample audit could catch one of these errors over a five-year period. But how many would they miss? This is why we often cite research by Professor Ronald Klimberg, Decision and System Sciences Department of the Haub School of Business, Saint Josephʼs University, that random sample audits miss more than 90% of
overpayments found by 100% comprehensive audits.
Facility Fees
A second article, Patients are Getting Blindsided by ‘Facility Fees’, reports on the growing issues surrounding medical claims for facility fees for physician and other provider visits that historically did not include facility fees. In many cases, the facility fees exceed the provider’s professional fees. As noted in the article, this is driving up medical costs and causing employees to question medical claims. When employees have cause to question the validity of medical claims, it is extremely important that employers can exhibit appropriate diligence in paying claims accurately. Failure to have annual audits of medical claims payments would be considered negligence by many plan participants and legal experts.
Avoid “being in the news” for reasons you do not want to experience – engage the best! At
Healthcare Horizons we have served large employers for several decades and were the first to
offer 100% comprehensive audits. We would enjoy discussing with you the many benefits of
our audit services.