EXAMPLES OF AUDIT RESULTS

What kind of payments errors and processing errors do we find in audits? You name it, we’ve found it. Below are just a few examples:

• In one audit, we found the TPA firm was systematically overpaying all Medicare-primary claims for an employer. As a result, the employer had us audit all Medicare-primary claims for a three year period and ended up recovering a large sum of money from the TPA firm.

• Kidney dialysis treatments are covered by Medicare after a certain time period, regardless of other group coverage. In this case, the TPA firm continued to pay dialysis claims for a patient long after Medicare became the primary coverage. We recovered $98,135 for the employer.

• A hospital claim for $245,259 was paid in full by the TPA firm. The claim should have been discounted via a per diem network pricing agreement. We recovered $159,585 for the employer.

• An employee had hip replacement surgery. The hospital billed for eleven hip implant devices instead of just one. The TPA firm paid the claim without question. We recovered $37,436 for the employer.

• An employee had an outpatient lab procedure for which the provider mistakenly billed $86,000 instead of $16,000. The TPA firm paid the claim in full. We recovered $69,743 for the employer.

• A TPA firm paid three claims in full during one year for gastric bypass surgery. The employer’s plan specifically excluded coverage of this procedure. The TPA firm reimbursed the employer for the $41,721 that had been mistakenly paid on the claims.
  
  
• In a recent audit we found 37 former employees (plus spouses and children) who were still being carried on the employer’s plan. Over $64,000 in claims had been paid out for these individuals, even though they were no longer eligible for coverage. Most of the money was recovered and all 37 employees, plus spouses and dependents, were removed from the plan roles.

• In a recent pharmacy audit covering a two year period, we found over 7,000 retail prescriptions and over 4,000 mail order prescriptions where the PBM firm had charged a higher dispensing fee than allowed by contract.
  
  
• We also found over 12,000 prescriptions that had been priced higher than the rates allowed in the employer’s PBM contract.