Last month, we examined a few of the top categories of claims payment errors. Because every healthcare claims data set has errors — people make mistakes — it is important for self-insured employers to perform an independent, fully comprehensive audit annually to identify errors, correct systemic issues for future savings and recover claims that were paid erroneously.
Rather than asking your employees to contribute more in terms of higher premiums or reducing their benefits, self-insured employers should ensure that their TPA is processing and paying healthcare claims correctly. It is an important fiduciary responsibility of the self-insured employer.
In this blog, we take a closer look at three more common data set errors.
Top categories of claims payment errors
- Duplicate payments
- Eligibility
- Coordination of benefits
- Medical edits
- Inpatient readmissions
- Multiple procedure reductions
- Out of network reimbursement
- Benefit maximums
- Benefit exclusions
Assistant Surgeon
Healthcare Horizons tests two common areas of overpayments for assistant surgeons: pricing and coding. Assistant surgeons usually receive a percentage of the normal fee schedule rate for the codes used with assistant modifiers, and we identify any claims paid that are greater than this rate. Additionally, we identify claims as possible overpayments for procedure codes that Medicare does not allow payment for an assistant surgeon.
Hospital Mistakes
Many payers across the country have adopted policies to investigate and subsequently deny payment for hospital mistakes and avoidable conditions, such as objects left in a patient during surgery, fractures incurred in the hospital, blood incompatibility and certain types of infections. We put expert eyes on claims data for these types of hospital errors and expect recovery opportunities as more administrators adopt such policies.
Medical Edits
We apply medical edits to the claims data to identify mutually exclusive procedures and cases of procedure unbundling. Mutually exclusive edits identify procedure combinations that cannot be reasonably performed on the same patient on the same day. Unbundling occurs when a provider bills multiple component codes versus a single comprehensive code, often resulting in higher reimbursement. Payers have discretion over which medical edits to apply as there is not a commonly accepted group of these throughout the industry, so we are generally looking for a reasonable application of a set of edits and questions selected claims that seem to be clear errors.
While many self-insured employers will say “Our TPA has us covered,” and most TPAs do a good job of processing claims, it is our business to conduct thorough, 100% Difference annual audits that return money to our clients. Our expertise and ability to dig deeper into claims data sets allows us to deliver a better return on investment for our clients.
The Difference is in Knowing.
To learn more about our approach to healthcare claims auditing or out-of-network provider fee negotiation services, visit Healthcare Horizons, or reach out to us at hhadmin@healthcarehorizons.com.
Randy King is president of Healthcare Horizons Consulting Group, Inc. The company is one of the nation’s leading healthcare claims auditing firms, focused exclusively on self-insured employers since 1999. Healthcare Horizons has recovered millions of dollars for its clients through auditing and air ambulance negotiations for some of the world’s largest employers.