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What You Don't Know WILL Cost You!

You've hired a professional administrator to pay your organization's medical and dental claims, and you're probably pretty happy with their service. Or, maybe you self-administer your plan, and your staff pays the claims in-house. In either case, you feel things are under control. But are they?

Did you know that, on average, professional administrators and in-house claims paying functions overpay nearly 1% of the dollars paid on the checks they issue? That's right! Our experience with hundreds of clients over the last three decades consistently shows that nearly 1% of payments issued were overpaid. And that's because administrators and claims staffs are hired to pay claims, and issue payments quickly, so your employees are happy. But, fast is not necessarily right.

Although 1% might not sound like much, it represents over $32 Million overpaid during a three year period for the nearly 90 clients we reviewed during that time. In fact, we found the average plan overpays more than $375,000 per year.

You might ask, "How could they overpay that much?" Well, we've seen hundreds of reasons why claims were overpaid.

Some of the most common mistakes are:

• Issuing duplicate payments or paying duplicate charges, due to making errors, such as entering incorrect coding, keying incorrect service dates or other data, paying charges under the incorrect patient's account (such as, member instead of spouse), and paying the incorrect provider

• Not taking PPO discounts, applying incorrect PPO discounts or allowances, paying incorrect PPO per diems, or entering incorrect repriced amounts

• Paying charges for non-covered services

• Paying charges that should have been denied due to workers' compensation

• Incorrectly paying non-PPO benefits because the PPO tapes had not been loaded timely by the data processing area

• Applying two times the outlier benefit in error

• Not taking the pre-certification penalty

• Not coordinating benefits or incorrectly coordinating benefits with the primary carrier

• Incorrectly taking a percentage discount instead of paying the per diem rate

• Incorrectly overriding eligibility

• Not applying per diem stop loss benefits

• Entering an incorrect counter

• Releasing payment for surgery charges before case management negotiated a discount

• Using incorrect per diem rates

• Paying for unbundled surgery or maternity charges

• Setting benefits up incorrectly on the system, for items such as coinsurance percentages, benefit maximums, deductibles, and mental nervous, substance abuse, and chiropractic limits

We know you want to minimize your health care costs. And you don't want to waste money on unnecessary claims overpayments. We will help you find those payment errors, so you can recover the overpayments, and make sure they don't happen again. And, if you prefer, we can help you collect payment errors we identify. We understand what you want, and at BPA, "What You Want, We Want."