TPA Paid 15% of Claims in Error
Audit Issue
Our client’s group health plan covered retirees age 65 and older. The plan stated clearly that only those services covered by Medicare would be eligible for payment under the employer’s plan, and that benefits would be paid secondary to Medicare’s primary payment. In our on-site review of only six months of paid claims, we examined claims paid without the necessary documentation of the Medicare benefit determination (Medicare Explanation of Benefits), as well as claims paid for non-covered services.
TPA Response
In their written response to our potential audit finding, the claims administrator acknowledged a systemic weakness allowing certain claims to be paid without pending for additional required information.
Audit Finding
Of 135 retiree claims reviewed on-site, 21 claims (15%) were paid in error.
Financial Error
The administrator agreed to financial errors of almost $48,000.00.