Are You Aware That You May Be Overpaying Millions of Dollars in Medical Claims? 

Duplicate Claim payments, payments made on behalf of retroactively terminated members and simple coding errors can easily reach these amounts even for a medium sized health plan.  Overpayment rates of 1% to 2% of medical expenses are common, and for even a small health plan or self insured employer, this can be well over $250,000 a year.

Duplicate claims are paid by health benefit organizations at an alarming rate. Added to this are a growing number of claims paid for on behalf of ineligible members and procedure code bundling that doesn't conform to NCCI standards. With margins so tight these days you can't afford mistakes, whether system or people-generated.  We can help you find those errors and identify the claims so you can recover your dollars.

Your claim system isn’t catching these claims. Even the best claim systems lack a comprehensive mechanism for determining and properly adjudicating duplicate claims, and as automated as you believe your claims processing to be, a large percent of claims - especially duplicate claims - are actually manually reviewed and approved and people do make mistakes.


Retrospective duplicate claims systems often are written to identify duplicates using very simple matching criteria and often don't catch "near" duplicates or allow sophisticated user defined search criteria.

We have found that most duplicate claims find their way into the system, and subsequently get paid, due to the following two reasons:

• Inadequate Reporting:  Electronic Claims is the worst offender when it comes to the proliferation of duplicate claims. Most systems issue reports of potential duplicates but the reports are often not even reviewed.
  
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• Data Entry: While entering on-line, some systems produce warning messages that may not be clear,  are ignored or simply bypassed to maintain claims "productivity".

And because members are moving in and out of plans so often these days, many organizations are also paying for services they are not responsible for.  Eligibility information is often available only after the fact – sometimes months after the actual event – and claims already paid based on this incorrect eligibility are often never recovered.

We also check claims for conformance to NCCI standards. The National Correct Coding Initiative (NCCI) edits are a series of rules developed by CMS to identify errors in two areas of procedure code submission. The Mutually Exclusive edits check for procedures that should not be performed at the same time based on standard medical practice, while the Comprehensive/Component edits look for codes that cannot be reasonably performed during the same session or day. These edits seek out coding pairs where the primary therapeutic outcome may have been billed along with a lesser “component”. NCCI edits are applied to outpatient and professional claims.

Pilot Information Systems offers a unique, risk free service to identify and report these potential overpayments.

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