This month’s Lost Benjamin Award nominee exposes a practice that is on the rise. Recently, Healthcare Horizons personnel found medical claims from a provider that had vaccine medications billed by both the physician and the outpatient facility. When we asked for a review, the third-party administrator (TPA) responded that the claims were paid correctly. When … Read more

March 2024 Lost Benajmins Award Nominee   Don’t Pay a Transfer Tax! Healthcare Horizons personnel continue to find instances of providers being paid full case rates for hospital inpatient admissions, despite patients waiting only a few hours in the original facility before a transfer to another facility for care. As a result, the self-insured employer … Read more

As more hospital systems evolve into integrated medical systems, which typically include physician medical practices, some organizations are billing for outpatient facility fees in addition to the historical professional fees associated with the medical provider’s services. Professional fees include coverage of the medical office’s facility costs, so the additional outpatient facility fee represents a duplicate … Read more

**WE HAVE A WINNER! Click here to see who was chosen by voters as the biggest culprit of Lost Benjamins!**     We’ve showcased 12 great nominees for our 2nd annual Lost Benjamins Award! Now it’s time to pick the one that was most impressive – or outrageous! Whatever metric you choose, we want to … Read more

A classic case of This Or That?   Water Hose OR IV?  Last month Healthcare Horizons’ personnel submitted an audit finding to a client’s third-party administrator (TPA) to review the resolution of a claim containing an obvious error. The claim was submitted for 1,000 units of J7120, delivered intravenously in one hour in an office … Read more

Despite auditing paid healthcare claims for more than 25 years, Healthcare Horizons and our clients continue to be stunned by some of our findings.  But this recent one seems out of this world. We identified a ground ambulance transportation claim for a patient with an orbital fracture. The patient was transported 45 miles for treatment. We … Read more

Recently Healthcare Horizons completed an annual audit for a long-term client.  The client’s contract with its third-party administrator (TPA) strictly limits audits to random sample audits, thereby not allowing comprehensive audits.  In performing prior audits, it was apparent that the TPA was erroneously paying certain claims, but such claims were not selected via the random … Read more

In recent months, we noted a record finding for a single claim recovery of over $1.7 million dollars for a client and a systemic error involving thousands of claims totaling over seven million dollars in recovery for a client.  We all recognize that news shows focus on big stories rather than daily routine events to … Read more

This month’s Lost Benjamins Award highlights the importance of persistence and perseverance. During the performance of a comprehensive audit for a large, self-insured employer, Healthcare Horizons noted claim charges based on a 22% fee rate that appeared to have no explanatory basis. It initially appeared to be a fee charged by the employer’s third-party administrator … Read more

Healthcare Horizons began the Lost Benjamins Award to highlight the importance of self-insured employers having annual audits of their paid medical claims. We share some of our audit findings to show how much money companies may be losing simply by not looking closely at their claims data. Some errors may appear to be small dollar … Read more