Background: A large health insurer contracted with Equian to complete a post payment review of their claims file. The client indicated that they had a pre-authorization program in place and that it was functioning appropriately.
Situation: The claim file was reviewed in detail by Equian experts who determined a total $4.9 million in overpayments related to authorization errors had occurred in the previous 18-month period.
Equian’s Role: Equian identified errors including payments for denied admissions, denied days, and authorization for lower levels of service. Further we reported that authorization overpayments were a six-fold greater problem on one of the client’s two payment systems.
Summary: Many payment systems do not have fully integrated authorization systems that prompt pop-up warnings or provide alerts of denied days, or non-covered services.
Based upon Equian’s findings, our client promptly initiated stopgap measures resulting in greatly reduced future authorization errors.