TPA Overpaid $134K
The Audit Finding of the Month is a new monthly installment we will share on our blog and Facebook page.
Audit Issue
In our on-site review of a claim for a patient hospitalized for a kidney transplant, we questioned the TPA's apparent disregard for primary Medicare coverage for end-stage renal disease (ESRD).
TPA Response
In their written response to our potential audit finding, the TPA stated that because the patient’s claims history did not include dialysis treatment, they did not seek information relative to potential Medicare coverage.
Audit Finding
The TPA incorrectly relied on the occurrence of dialysis treatment as the sole trigger for Medicare coverage when Medicare coverage also becomes effective the month a patient is admitted for a kidney transplant procedure. While a 30-month coordination period must be applied for Large Group Health Plans (LGHPs), claims administrators should accurately track Medicare coverage so that the employer’s plan is relieved of primary responsibility at the earliest possible date.
Financial Error
The administrator agreed that this claim was overpaid by more than $134,000.00, an amount recoverable from Medicare.