AUDIT RESULTS

What kind of payment errors do we find in our audits? The following examples are from actual audits we have recently conducted:

• A hospital claim of $245,259 was paid in full by the Carrier. The claim should have been discounted via a per diem rate network pricing contract. We recovered $159,585 for the employer.
• A claim for inpatient rehab was not authorized and should have been denied. The Carrier paid the claim without question. We recovered $22,378.53 for our client.
• An employer’s plan excluded coverage for gastric bypass procedures, but the Carrier paid three such claims in full. As a result of the audit, the Carrier agreed to reimburse the employer for the full amount on the claims.
• A Carrier paid a hospital claim for $18,256, even though the claim form clearly showed Medicare as the patient’s primary coverage. We had the provider re-file the claim with Medicare and recovered $17,416 for the employer.