Insights

In our years serving the needs of self-insured employers, Healthcare Horizons has successfully recovered millions of dollars in healthcare overpayments. Here are a few case studies detailing more specific examples of how our auditing services have helped our clients recover overpaid or inaccurate healthcare claims. In each of these cases, the chance that a random sample audit would have identified the error is a reflection of the type of audit: random.

CASE STUDY #1

Healthcare Horizons identified an instance for a client in which a surgical implant was billed incorrectly at $777,000 versus $77,000. As the reimbursement was based on a percentage of the charges, the billed charge amount had a significant effect on the final payment, resulting in an overpayment of $300,000. Initially, the claims administrator responded that the claim was correct and that a high-dollar review (second-tier review when claims exceed an established dollar threshold) had already been performed. However, Healthcare Horizons was able to demonstrate a probable billing error based on the type of implant billed; we consequently convinced the claims administrator to follow up with the hospital, which then acknowledged a keying error resulting in the overcharge. The result was an overpayment recovery of $300,000 for our client.

CASE STUDY #2

One of our clients had a member arrive at the emergency room with a potential shoulder fracture; the patient was provided an X-ray examination and an arm sling. The hospital incorrectly billed for 1,400 arm slings, and the claim administrator paid the claim at $150,000. Healthcare Horizons identified the error, and once the claim was corrected, the payment was reduced to $1,000, resulting in a recovery of $149,000 for the client.

CASE STUDY #3

Healthcare Horizons identified an issue for a client regarding the administration of a skilled nursing benefit maximum. The overpayments were due to a combination of inconsistent billing by the facilities and manual processing by the claims administrator. After the review by Healthcare Horizons, the client recovered more than $1 million in overpayments, and a root-cause correction was implemented to prevent future overpayments.