Services covered regardless of being an excluded benefit
Audit Issue
The group medical plan document clearly defines its coverage of speech therapy services as those necessary to restore normal speech following injury or illness (e.g. head injury, stroke, serious brain damage). The plan specifically excludes any benefits for speech therapy to treat developmental speech delays.
TPA Response
In its written response, the claims administrator stated that the initial “benefit checklist” used to configure the claims system did not address speech therapy for developmental delays. Upon finalization and issuance of the Summary Plan Description (SPD), the language adopted for speech therapy coverage and exclusions was not effectively communicated to the claims department for programming revisions.
Audit Finding
Sample claims selected for audit exposed extensive benefits paid for ongoing speech therapy for children with diagnoses such as expressive language disorder, lack of normal physiological development, and other speech disturbance (with no physical cause).
Financial Error
For the ten audit samples we reviewed on-site, benefits were paid in excess of $36,000 for developmental speech therapy not covered by the plan. The administrator agreed to prepare ad-hoc reports to quantify the overall financial impact of the error.