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Spring Cleaning – Time for a Claim Audit!

If we audited your employees medical claims what do you think we would find? Surely, you’d expect your TPA paid the claims accurately and timely, right? They correctly apply your benefit schedule (co-pay/deductible), pay providers and facilities quickly, report high dollar claims to your stop loss carrier, and service your employees efficiently. Yet, rarely does that happen; certainly not 100% of the time.

In fact, there are industry standards for the number of errors the TPA can make and still be considered performing at a “best practice” level. Your hope is that they fall within those standards. Especially since they have access to your company’s bank account and directly withdraw your money to pay those claims they’re processing!

We met with a client in December 2015 and presented them with over $30,000 in errant payments their TPA made on their behalf. These included duplicate payments, subrogation errors, and not seeking stop loss reimbursement on a large dollar claim. In addition, we found multiple instances of the employees being charged higher and lower co-pay amounts throughout the plan year. These errors were found on a sample of 400 out of 10,000 claims.

The role of a health insurance Third Party Administrator is often highly automated, but you might be surprised how much human interface there is. And, as we all know, the more human interaction involved, the more mistakes that can be made.

Open the windows, beat the carpets, scrub the floors and, for the love of God, have KBM perform a Quality Assurance Medical Claim Audit for your self-insured health plan.

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