Recovering overpayments from providers can be a contentious process, fraught with potential for abrasion and even litigation. Health plans must perform advanced statistical analysis and extensive medical record review in order to achieve the level of documentation needed to confidently request reimbursement with any likelihood of success. While technology can identify potential instances of inappropriate billing, actually seeing an investigation through to completion and recovery requires extensive statistical analysis, teamwork, and communication.

Faced with such a challenge, Health Partners Plans, a not-for-profit managed care organization serving more than 258,000 Medicaid, Medicare, and CHIP members in Pennsylvania, achieved an ideal outcome, successfully recovering more than $1 million in overpayments related to upcoding from a provider group.