Medical Claim Audits – Lessons You Can Learn… From Lessons We’ve Learned.

Over the past 25 years, we’ve completed a lot of audits for a variety of different businesses. It’s safe to say that when it comes to auditing healthcare claims, we’ve seen a lot and, with that, have learned a lot. With every rock that we’ve turned over, a unique set of circumstances, needs and objectives presented their own challenges. But it’s when we meet these challenges, and the results are revealed, that we are the most satisfied. In turn, the lessons we learn from each audit become invaluable to us, to our clients and, now, to you.

Turning over rocks. Medical claim audit lessons you can learn… from lessons we’ve learned.

If you’re thinking….

“My last audit of the administrator was very good and uncovered very few errors; I don’t think I need to audit them again.”

Then, you should know…

Just a year ago, we audited a third party administrator and found very few errors. Everything appeared to be in control until the client made a few plan changes and the TPA encountered some staffing turnover. Suddenly, financial and procedural accuracy dramatically declined with this year’s audit results. Fortunately, this was discovered right away and five years didn’t go by in between audits. Imagine the amount of money that would have been spent incorrectly!

If you’re thinking…

“My administrator has calculations automated so they will always be correct.”

Then, you should know…

Whether it be automated bill paying or automatic answering services, most of us have encountered problems with automation at some point in our lives. The healthcare industry is no different in that the automatic processes used by administrators can be quite susceptible to error. Accumulated benefits, specifically, provide many administrators headaches because they are so prone to mistakes. With claims from both pharmacy and medical coming together to meet a single deductible, we regularly find that accumulated benefits exceeded the deductible amount.

If you’re thinking…

“My TPA would never pay claims to people that aren’t enrolled.”

Then, you should know…

We recently audited a loyal customer, and the results showed something quite alarming. Our eligibility screening found that claims totaling over $1 million had been paid to individuals after they were no longer eligible for benefits. In some cases, this was well after their termination date. Our client was able to request refund amounts paid for the ineligible members, and, just importantly, their administrator took remedial actions to detect and deny claims for ineligible persons. Why pay for someone’s claims when they aren’t even on your payroll?

Let the twenty-five years worth of lessons we’ve learned teach you how to save money. To find out if your self-funded health plan could benefit from a CTI audit, please click the graphic below for our Stop The Leaks Checklist. If you’d like to speak to one of our industry-leading medical healthcare claim audit specialists, please contact us here.


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