The audited health plan specifically excluded services relating to pregnancy of a dependent child except for complications of pregnancy.
Multiple claims were identified as being paid for excluded routine pregnancy services.
The claims administrator agreed that claims were paid in error. In investigating the root cause of the error, they discovered a systemic flaw stemming from the plan’s allowance for complications. Apparently, the exception criteria were set up too broadly to automatically deny even routine services.
The administrator agreed to recoverable financial errors of more than $79,000.