TPA Overpaid More than $195K
Audit Issue
Our client’s group medical plan specifically excludes any and all surgical procedures related to the treatment of obesity “unless surgery is performed by an in-network physician using an in-network facility”.
TPA Response
The administrator confirmed our findings that bariatric surgery expenses should not have been reimbursed to out-of-network providers.
Audit Finding
The TPA traced the origin of the errors to a “system glitch” which focused only on deductible, copay, and/or coinsurance differences related to out-of-network status. The system failed to deny benefits for certain services excluded by the plan when provided out-of-network, and a manual review by a claims processor was not triggered.
Financial Error
The administrator agreed to financial errors of about $195,000.
For previous Audit Findings of the Month, click here.