Examples

The following are interesting examples of non compliant overpayments.  For
additional case studies and productive recovery types, please contact us.

Charge master audit

In the Northeast, a hospital with a market dominant position and with a 2% annual
charge master increase authorization developed new revenue codes for room and
board charges and then increased these new room and board charges 2%
quarterly.  The result was an effective price increase to the payer of 30% in room
and board alone.

Centralized billing function errors resulting in double payment

When providers through affiliation, ownership, or management have an effective
local market share greater than 20%, duplicate bills are occasionally submitted and
paid for the same patient for the same service.  The affiliated, owned, or managed
provider bills through a centralized claims processing function using different
provider identification numbers (PINs) or tax identification numbers (TINs).  Because
the hospital uses a different PIN or TIN, the claim appears to the payer as a new bill.

Chart audit

In the Midwest, a hospital separately billed oxygen while the patient was allegedly in
the intensive care unit.  Upon audit, the patient’s room assignment was reclassified
to a routine bed from an intensive care bed; the oxygen charges were also
recouped.

Claim line variation resulting in double payment

Few payers have edit screens that detect duplicate claim lines within a claim.  Most
payers’ edits identify mirror duplicates but not duplicate claim submissions where
one or more fields in the second claim have different values than the same field in
the first claim submission.  Duplicate payments for non-mirror claim submissions
occur most often as a result of late bills generally submitted 30 days after the first
claim submission.

Many payers unknowingly pay duplicate claims when the billed amount of the
resubmitted claim differs from the original claim submission by as little as $1.00 – all
other fields are the same.  Reasons for these overbilled claims and the resulting
overpayments depend upon the payer’s claims processing platform, the provider’s
claim preparation and submission practices and, if applicable, the payer/provider
agreement.

Claim audit

In the Southeast, a hospital had an ER case rate, inpatient per diem, observation
bed hourly rate, and percentage of charge outpatient rate.  With the patient
originating in the ER, on the same day of service, the patient without moving out of
the ER but upon ER triage was then discharged from the ER and registered as an
outpatient for both a CT and MRI, discharged as an outpatient and registered as an
observation bed patient, and prior to the census taking hour, admitted.

Because the inpatient admission was preceded by an observation bed charges,
and all other services were billed separately, the ER and OPT charges (and
payments) were not bundled into the inpatient case rate.

Double payments when the revenue and CPT codes are duplicated

Some providers interchangeably use the more global revenue code with the more
specific CPT code and erroneously overbill for duplicate claim lines within a claim.  
There are some revenue codes that specifically describe the service provided and
can be matched with the CPT code to determine if the patient received a physically
impossible number of the same services on the same day.

Census taking hour overpayments

Since few commercial payers specify the census taking hour, particularly for
outpatient services, some hospitals redefine their census taking hour based on the
payer and the service provided to the payer’s member.  For outpatient surgery
services paid on a case rate with reduced payments for the second procedure on
the same day, some hospitals, after completion of the first procedure, discharge the
patient and then for the second procedure, re-register the patient using the
subsequent day’s date.

The bills are submitted separately and since the service appears to have been
provided on different days, the hospital or outpatient facility is paid at 100% of the
contracted rate for both procedures.