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The Importance of Benefit Claims Examinations

What is a claims examination and when should you consider obtaining one? A claims examination is a test of claims designed to identify overpayments and can cover medical, dental, vision and other types of health benefits. It should be performed by an independent firm or person that specializes in this type of work—ideally a firm or department exclusively comprising professionals experienced in this field.

An experienced claims examiner will select a sample of claims paid and re-exam each based on your plan of benefits. Examiners are trained to be alert to the many ways a claim can be overpaid. For example:

  • Has all of part of a claim been paid in duplicate? Don’t count on the benefit provider bringing duplicate payments to your attention, or participants notifying the carrier.
  • Does an employee’s spouse have his or her own group policy? Did your carrier properly investigate it?  This is one of the most common causes of overpayments when primary insurance is overlooked or incorrectly applied.
  • Does your plan have a third party liability clause?  If so, you have the right to recovery for claims paid in accident claims when there is other insurance coverage such as workman’s compensation, or a lawsuit. Many times these claims are never investigated, or pursued for recovery.
  • Eligibility Problems?  Is eligibility information updated timely? If not, claims may be paid before information such as termination, or cobra payments are posted in the claims system.
  • PPO Claims? PPO providers generally negotiate contracts with vendors, which can be quite complicated. Unless the examiner has experience interpreting such contracts, there is a large margin for error.

An independent, experienced second look is a valuable tool to identify inconsistencies or questionable claims. Examinations performed by a knowledgeable professional are generally money well spent.

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