Case Studies > High Patient Co-Pay

Suspiciously high patient co-payments prompt investigation; processing error discovered and claims paid

Key Takeaways
  • Titan staff discovered two outpatient claims where each had $27K transferred to patient responsibility

  • Auditor called the health plan and found that the two claims had been processed as out of network in error

  • Patient is no longer responsible for $54K of medical bills and the hospital has received full payment

Overview

While auditing paid claims for a hospital client in Arizona, Titan staff discovered two outpatient claims where each had $27K transferred to patient responsibility.

The Challenge

Although the two claims initially appeared to have been processed correctly, it seemed unlikely that the hospital would be able to collect this sizable balance from the patient. Based on Titan’s claim payment experience, a $27K patient balance due for a single outpatient visit seemed very suspicious. The auditor investigated further to determine whether the claims had been processed according to the terms of the contract.

The Solution

Titan’s research found several instances of the same medication being administered to the patient during numerous visits within the same calendar year. On all previous claims, the patient had $0 applied to patient responsibility. The auditor called the health plan and confirmed that the services were, in fact, authorized. When pressed to explain the payment discrepancy, the health plan admitted that the two claims in question had been processed as out-of-network claims in error. After the auditor verified that the facility was still a contracted provider, the health plan agreed to reprocess the claims and paid them both ten days later.

The Results

A very grateful patient is no longer financially responsible for $54K of medical bills and the hospital has received full payment from the payor on the two underpaid claims. Hospital collection staff are also now more aware of unusual balance transfers to patient responsibility.

By the Numbers

$54K

Amount Collected