Earlier this year, Healthcare Horizons reported finding the largest overpayment of a single claim in our history. The lost Benjamins totaled over $1.5 million dollars arising from the duplicate payment of a single medical claim. We thought that record overpayment of a single claim would stand for at least a couple of years.
We were wrong.
We recently found an overpayment of a single claim of over $1.7 million dollars! Obviously, it was a very large claim and the third-party administrators’ (TPA’s) payment protocols required such a large claim to be manually adjudicated by an experienced employee. Unfortunately, when calculating the amount to be paid, the claims processor erroneously applied the percentage to be discounted from billed charges.
Math Mistakes Matter
The claim should have been adjudicated at only 16% of billed charges. Instead, the claim was merely discounted by 16% (adjudicated at 84% of billed charges.) The result was an overpayment to the provider of over $1.7 million dollars. The error was not detected by the TPA’s review processes and was not reported by the provider.
Healthcare Horizons’ audit of all claims utilizing our targeted audit processes, ensures such errors are discovered. A random sample audit does not provide such assurance. In today’s challenging economic environment, it is important that employers do not incur unwarranted healthcare costs.