Medical Claim Audit Success Stories #2
These bottom line boosts can be seen through our whole span of audit services. Savings can be realized not just in the auditing of Medical and Dental health claims but in a number of other areas, including the public sector, hospitals, health systems and associations. Take a look below at some more of our recent audit success stories.
CASE STUDY: PAYMENT OF INELIGIBLE EXPENSES
We were called to complete an audit on a smaller sized technology company to ensure that claims were being paid correctly. Using our cutting-edge software, we were able to show that over 9,000 claims for chiropractic modalities had been paid by the administrator, although the plan excluded paying such services.
The CTI Difference: $300,000+
When faced with the facts, the carrier acknowledged that the system had been programmed incorrectly and the client was reimbursed in the amount of $300,000.
CASE STUDY: ERRORS IN PHARMACY PLAN DESIGN SETUP
When a client came to us with some concerns over their PBM, our analysis revealed a serious diagnosis. It showed their plan design had flaws relative to copay rulings as well as formulary coverage.
The CTI Difference: $240,000+
After our audit showed a an overall potential recovery of close to $550,000, the PBM agreed to reimburse our client with approximately $237,000, and continued recovery efforts followed.
CASE STUDY: J-CODE SPECIALTY DRUG ANALYSIS
After analyzing one million medical claims, and 500,000 pharmacy claims for a large technology firm, we found 10,000 medical claims that were billed with a “J-Code.” A J-Code is used for drugs that can’t be self administered, like chemotherapy or dialysis. The claims had been processed with a fee schedule used by the employer’s PPO plan.
The CTI Difference: Opportunities for $100,000 in savings.
Once we identified this code, we created a cost comparison analysis to determine how the claims would have been paid had they been submitted to a Pharmacy Benefit Manager (PBM). Going forward, the client will save an average of 20% on specialty drugs distributed by the PBM rather than paying for these drugs through their PPO network.
Health care claim audits can help your business. To find out how CTI can stop the leaks and fix your financial future, please click here or contact us at anytime. We’d love to speak with you.
