Typical TPA Issues / Case Study / Questions to Ask / TPA and Provider Audits / Consulting Services
MBAA typically uncovers provider overcharges and TPA overpayments in the amount of 6 FIGURES for a single plan year!
If you could get that money back, would you?
It is no longer a secret that over 90% percent of medical bills contain errors. Most of these errors result in money being owed to your company and/or your employees. Is your TPA catching these errors?
Real Life: What we've identified in self-insured reviews
- Service agreements (contracts) between TPAs and self-insured companies are written by the TPA, to protect TPA’s interests; this can translate into unanticipated and unforeseen expenses for the self-insured company.
- Audit clauses are designed to deter the self-insured company from performing independent audits of claims adjudication.
- Re-Insurance contracts signed by the TPA and Re-Insurance, and not by the Self-Insured and Re-Insurance, limit the self-insured company’s access to information.
- TPA’s software-based edits (to catch billed errors) don’t always cover the limits or restrictions self-insured plans may require. The costs of adding edits specific to each company plan outweigh the TPA’s profit from your company’s addition to his client list.
- TPAs rarely perform detailed hospital bill audits. Time would not permit them to, and hospitals are very much aware of this fact.
- This list goes on!
The heart-wrenching aspect of this business is watching corporations being forced to downsize the coverage they offer to their employees. Worse yet, businesses are closing due to lack of funds for employee healthcare.
Case Study
While working for one corporate client, MBAA exposed a major university hospital that had incorrectly billed one line item on every pacemaker bill, resulting in consistent overcharges of $33,393 per bill! They were charging for this line item in addition to the already billed charge for the pacemaker totaling $57,000. Until it was exposed by our detailed hospital compliance review, insurance companies and every TPA had paid this so-called glitch--since 1999. The hospital now reports they have taken care of it in their system--but they did not mention voluntary reimbursement to all TPAs and insurance companies that had paid the charge in the past.
So Ask Your Self These Questions
- What error rate does your TPA define as acceptable error rate?
- When was the last time your company received a refund check?
- Does the 20% to 40% discount really make up for massive overcharges appearing on hospital bills?
- Have you hired an expensive check -writer?
Comprehensive TPA / Provider Audit
Our comprehensive bill review service results in a detailed report of findings, including the scope of the errors we find, the ramifications of the errors from a financial perspective, and a description of the advantages to be gained or disadvantages to be incurred as a result of these findings. We also report any potential risk or problem areas based on patterns we identify throughout the process, and suggest cost saving procedures you can implement internally. We also:
- determine compliance with both contract terms and plan provisions.
- evaluate accuracy of provider billings and highlight TPA overpayments:
- Assess for potentially abusive or fraudulent claims, per provider profiling, by evaluating subscriber claim history, and other analytical techniques.
- We recover overpayments from providers and TPA’s
Consulting Services
In addition to the Comprehensive TPA/Provider audit, MBAA's advocates also offer expert consulting services to make sure your TPA stays on track all year long. Our consulting services include:
- Analysis of all service agreements for the self-funded’s protection
- Development of company-specific reports from TPA
- Quarterly claims audits
- Itemized
statement
h
ospital
bill reviews
- Other services personalized for your company
Contact an advocate today, or call the MBAA corporate headquarters for a referral: 540.387.5870.
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