Lost Benajmins Award Nominee: May 2023
After many years of developing medical edits to identify excessive charges for medical professionals, facilities, devices, implants and other medical services, many third-party administrators (TPAs) report very high accuracy in paying claims. However, Healthcare Horizons continues to find extraordinarily large overpayments that are undetected by TPA’s adjudication software and audit procedures.
An Error Might Not Always Look Like an Error
As evidence, we recently identified a payment made by a TPA of $80,000 for implantable mesh during an outpatient hernia surgery. A reasonable payment would have been less than $2,000. When reported to the TPA, their only explanation was that the $80,000 was the amount billed by the provider. Needless to say, the employer did not consider that to be a reasonable explanation for such an egregious payment.
When considering a $78,000 overpayment, It seems obvious that the claim was filed inaccurately. Yet, the TPA missed it.
Comprehensive Audits Protect Your Budget and Bottom Line
Inaccurate claims can result in your healthcare plan losing thousands of dollars due to overpayments. With our distinctive 100% difference auditing process, we identify these errors and mark them for recovery. Not only do incorrect claims affect the immediate payout, but they also impact the affordability of your plan. Avoid paying for erroneous claims that artificially inflate the payout figure.
Remember, the provider of a healthcare plan (that’s YOU, the employer) is responsible for errors in medical payments. Safeguarding your company’s financial well-being requires fulfilling your fiduciary duty by preventing overpayment of claims. We are here to assist you in this endeavor. Reach out to us today to discuss the potential cost and savings you can anticipate through a thorough audit, enabling you to allocate funds in next year’s budget accordingly. Let’s ensure a healthy bottom line for your company. Contact us now!