This month’s LBA resulted in policy changes and future savings for all users of a certain third-party administrator.
In our prior nominations for the Lost Benjamins Award, we have cited enormous overpayments of healthcare claims that our clients are stunned to learn have occurred and only detected by Healthcare Horizons’ audit processes. Recently, we reported on the largest single claim overpayment recovery in our history totaling over $1.7 million dollars. This month, we are noting an audit finding having enormous monetary benefit to our client for many years to come and, surprisingly, other employers.
In reviewing the provider manual of a major third-party administrator (TPA) during the initial stages of performing a comprehensive medical claims audit for a large, self-insured government employer, Healthcare Horizons personnel noted a lack of clarity for readmissions that may be authorized for reimbursement. Our colleagues noted the ambiguous language could be interpreted to allow all types of readmissions to be eligible for authorization review.
Fast forward one year later. Healthcare Horizons personnel were reviewing the same TPA’s provider manual as an initial step in another client’s audit and noted the TPA had modified its readmission policy language. The revised language addressed the various issues we had raised and resulted in appropriate limitations on authorizations for payment. We informed our government client of the changes and the estimated impact of millions of dollars in future savings on readmission payments. We are also proud to note that all self-insured employers utilizing that TPA will also benefit significantly from our efforts.
In closing, this is another example of why we strongly encourage all large, self-insured employers to engage highly qualified audit firms to perform comprehensive medical claims audits annually. The employer and its employees will experience savings on their healthcare costs. Also, overall healthcare costs would be reduced as TPA’s address audit findings such as the one noted above, resulting in savings across more employers and their employees.
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