The Problem!


“It’s impossible to serve as a fiduciary while not having access to claims data, the ability to hold providers accountable by auditing detailed bills or providing transparency in cost and outcomes to guide participants.” – Forbes, May 26th, 2016

The term “overpayments” refers to healthcare reimbursement claims that were, for whatever reason, paid at an amount higher than the amount owed by the health plan to the recipient.

There are many different causes of overpayments, such as duplicate billing, third party liability, outright billing fraud and several others. Many overpayments are impossible or prohibitively difficult to avoid; even the best-run plans commit them. In fact, overpayments are a relatively predictable phenomenon…and a costly one. Providers also utilize new billing technologies and Revenue Cycle Managers to create billing strategies in order to creatively get around administrators’ claims adjudication and payment processes in order Maximize Revenues!

A 2014 report estimated the global average cost of overpaid health claims to be about 7% of all claims. The most recent analysis of Medicare claims puts the figure at 13% for fiscal year 2014. What’s more problematic, recently expanded coding rules make claims even more complex! Health plans that rely on third party administrators (TPAs) to administer claims on their behalf are believed by some to be at even greater risk. Although, self-funded employers using carrier TPA services under an ASO arrangement are also at great risk as these administrators DO NOT (although claim that they do) audit claims prior to payment, nor do they provide access to any of your claims data nor do they offer analytical reports to help you better manage your plan assets! In addition to those challenges, many times their own Network Provider Agreements actually protect those providers from audits and also dis-allow the application of standardized billing/coding rules set by CMS, OIG, NCCI and other government regulatory agencies thus forcing the Plan Sponsor to overpay!!

Furthermore, health plans’ contracts with providers typically include an explicit right to recover overpaid claims. Of course, some overpayments are difficult and costly to detect. And detecting an overpayment is not the same as recovering it. Out-of-network providers, for example, may have little obligation or incentive to refund an overpayment. And a fraudster who has been put in jail – or fled the country – can be nearly impossible to collect from. And of course, recoveries take time – several months to several years after the paid date, depending on the situation.

The Solution!

Clients can reduce their medical claim costs by 2-4% or more off of their annual medical spend, and routinely receive double-digit returns on investment, by performing a Comprehensive Medical Claims Audit and Recovery project which only requires a total of approximately 8-10 hours of the client’s time over the course of the entire project (9-12 months in length). In addition to the opportunity for economic return, our audits help health plans and fiduciaries fulfill their legal and managerial responsibilities.

Audits are one of the most direct steps one can take to show that they have met their legal obligations in assuring that all plan expenditures are warranted and that plan assets are not misspent.

Our solution is a COMPLETE solution—Planning/Customization, Data Intake/Verification, Analysis/Audit Execution, Audit Reporting and Full Recovery services that deliver recovered funds directly to the client. The various comprehensive audit modules utilized are as follows:

Recovery from Third Parties

  1. Coordination of Benefits (COB)
  2. Medicare primary payment (aged, disability)
  3. End Stage Renal Disease
  4. Duplicate payments (multiple payers)
  5. Subrogation

Claims Overpayments

  1. Claims for not-covered benefits
  2. Claims in excess of employers’ Specific Stop Loss
  3. Payments greater than charge

Provider Payment Validation

  1. Medicare Correct Coding Standards: (un-bundling, up-coding, excess billings, etc.)
  2. PPO Missed Discounts
  3. Duplicate Payments (provider paid twice)

Cases for Focused Follow-up

  1. Potential divorce
  2. Other insurance unknown
  3. High dollar cases

Eligibility Verification

  1. Payer Eligibility File Tests
    – Claimants not on payer eligibility file
    – Claims incurred outside periods of payer eligibility
  2. Employer Payroll File Tests
    – Claims paid for members not on employer’s payroll file
    – Claims incurred outside periods of employer eligibility
  3. COBRA Eligibility File Tests
    – Claims paid for formerly covered persons not on COBRA file –
    – Claims incurred outside COBRA eligibility dates
  4. Other Eligibility Verification Results
    – Overage dependents
    – Retired members still active on health plan

Our Post Audit Follow Up and Collection activities have analysts continuing to monitor claim payments and recoveries, reviewing payer collection efforts, and challenging case closures, where warranted. This results in Process Improvements and a more effective and efficient adjudication process for the client on a go forward basis.

What should I expect?
Click here to see what others have experienced.