- The shop billed you for five tires when, everyone knows, most cars only require four.
- Your credit card bill shows a charge for a one-way flight to Helsinki, and you have to google Helsinki to even know where it is.
Most of us know when something looks wrong. We check, we question, we fight to keep our money.
But as an employer, do you know when you’re being overcharged for employee medical claims that were in error, were fraudulent or were for procedures that never took place? Have you paid for:
- A circumcision on a newborn female?
- Five screws (at several thousand dollars each) when the surgeon only used two to stabilize a tibial plateau.
- An ultrasound that was never taken.
Probably. Every year employers pay more in claims than they need to and they aren’t armed with enough information to question the charges.
How is this possible? Isn’t someone looking out for you?
With many insurance carriers or third party administrators, the answer is, “No.”
For many insurance providers, automated adjudication is the technological answer to the expense and time spent during the claims process. Rather than having trained human eyes looking at claims, many carriers rely on software to automatically review claims which results in overpayments. It saves them administrative money and proponents suggest it speeds the claims process by making it more efficient. That might be good for them, but as an employer it could be very bad for you .
Auto-adjudication does not detect billing errors or fraudulent practices. As long as things seem reasonable and are within parameters pre-set in the software, claims are automatically passed through the system and on to you. No one questions the possibility that:
- There was no need for a second ultrasound the day after the original one was completed.
- Way too often similar lab charges are originating from the same mental health clinic for a handful of patients.
- While a pack of five orthopedic screws was opened, only one or two were used.
Part of the problem lies in the fact that healthcare providers bill insurance carriers and third party administrators with a Uniform Bill; basically a bundled charge. If there is an error or extra charge, auto-adjudication cannot see down into the charges to extrapolate problems. It takes trained eyes to know when something seems amiss and then it takes digging into bundled charges to uncover the error.
Some charges are errors. It happens. Some charges are simply fraud. Many unscrupulous providers and labs have figured out the auto-adjudication limits; i.e. how to crank out the claims without calling attention to themselves. Both errors and fraud can cost you thousands of dollars per year if they are not caught.
MBA Benefit Administrators doesn’t rely solely on auto-adjudication. Through our contracts with highly qualified organizations, board certified physicians and team members review your claims. These are people who work in healthcare. They know what is typically ordered for presented conditions or injuries. They know, for example, that two back-to-back ultrasounds are out of the norm and the second one probably didn’t happen, or that five screws weren’t needed for that tibial plateau stabilization. Their eyes become your best friend.
When a bill looks wrong we dig into the reason. If the bill is correct, we apply our deep discounts. If the bill is incorrect, appropriate actions are taken to correct the bill, then our deep discounts are applied. Either way the client pays less.
That’s just one example of the MBA advantage. See some of the others.