A Focused Sample Medical Claims Audit we conducted revealed that 19 of 250 audited claims were overpaid. These claims were all paid to one provider. Our medical claims audits revealed that a contract pricing schedule had been incorrectly loaded into the TPA’s claims payment system. Our medical claims audit recovered over $200,000 for our client..
MedReview performed a Pharmacy Audit for a large home services company. The pharmacy claim review covered a two year period. We discovered over 7,000 retail prescriptions and over 4,000 mail order prescriptions in which dispensing fees were paid in excess of the amounts allowed in the PBM contract. We also discovered over 12,000 prescriptions that had been priced higher than allowed in the contract.
A hospital claim of $245,259 was paid in full by the TPA. A MedReview Focused Sample Claims Audit revealed that the claim should have been discounted according to a per diem network pricing agreement. As a result, $159,585 was recovered for our client.
A Random Sample Claims Audit MedReview conducted revealed that $47,312 had been billed by the provider for implants. The claim was for a gallbladder removal which involved no implants. After our medical claims review, the provider refunded the full amount to our client.
An Electronic Claims Audit revealed that the TPA had loaded the incorrect Coordination of Benefits formula into its system and, as a result, had been incorrectly paying our client’s COB claims for over two years.
MedReview performed an Operational Medical Claims Review for a large transportation company. We found that the TPA was systematically overpaying all Medicare-primary claims. Our client then requested that we perform a medical claims audit on all Medicare Primary claims paid over a three year period. . This process resulted in recoveries of over $300,000.