Healthcare Horizons: Case Study 1



		A manufacturing organization with 2,500 employees engaged Healthcare Horizons to conduct a medical claims review. Employees were clustered around several manufacturing facilities and the corporate office, so members were generally accessing providers in a few localized areas. Total medical expenses for the period January 1, 1999 through October 31, 2000 were approximately $21 million. This company was using a large, national payer in an Administrative Services Only contract to process their claims. With members in different regions, multiple networks were needed to cover all of the participants, and one area network was created specifically for this organization. The largest issue identified during this review was that the payer was unable to accurately connect members to the contracts associated with their specific network. This caused significant problems in payment accuracy in the area of contract compliance. Healthcare Horizons was also able to identify problems with duplicate payments, eligibility and out-of-network benefits. Upon completion of the project, roughly $1 million or 5% was identified as overpaid and $557,000 was recovered. Contract non-compliance was the largest single area, contributing to collected overpayments in excess of $200,000.