How a Review of One Medical Claim Saved $2.7M

How we helped one client recover plan dollars

Across a range of clients, we've helped plans recover millions of dollars by reviewing their claims. Here's how we helped just one with a medical claim review.

The issue

A West Coast organization with 5,400 covered lives experienced a multimillion-dollar medical drug claim. 

They issued payment for the claim but given its extraordinary size, they requested Segal perform a special audit of this hospital claim. The organization did not have stop loss insurance, so this claim would have had a significant impact on their reserves.

Our solution

After our review for the drug product, Acthar, Segal’s Benefit Audit Solutions professionals determined that a billing error occurred. Segal requested additional information and a clinical review from the organization’s health payer.

The payer’s review confirmed the error and then referred the claim to its internal Special Investigative Unit (SIU).

After its investigation, the SIU identified an additional claim error and determined that the billing errors were not deliberate or fraud on the provider’s part.

The result

The organization accepted the provider’s $2.7 million settlement amount for both claim errors. The health payer implemented additional claim reviews and reporting solutions and also considered financial improvements to the organization’s contract renewal.