Are Your Plan Limits Really Limiting?

It’s not uncommon for health plans to include limits on benefits available for specific services or treatment of certain conditions. Examples include dollar caps and/or frequency limits on obesity surgery, infertility treatment, durable medical equipment, prosthetics, etc. Claims administrators are generally pretty quick to provide assurance to plan sponsors that they can in fact administer these design limits precisely as intended.

Experience with health claim audits shows us a different picture, however. Surprisingly often, we find  that administrators are not applying limit provisions accurately, resulting in substantial plan overpayments. A traditional, full-scale random claims audit may fail to identify and correct these errors. Rather than a traditional audit, consider a targeted electronic test of your claims history to see if overpayments might exist. Based on the results, you can then decide the value of following up with an on-sight audit.