Case Studies

During a proof-of-concept engagement, Penstock analyzed historical claims data for a commercial health plan and uncovered a systemic configuration error causing routine E&M services to reimburse at dramatically inflated allowed amounts. By mining paid claims data rather than relying on pre-pay edits or known error checks, Penstock identified approximately $1.8M in overpayments and enabled the plan to correct the issue at its source.

After a vendor found no issues, Penstock’s second-look chart review uncovered three unsupported diagnoses—correcting DRG severity and ensuring accurate reimbursement.

Penstock uncovered $2.5 million in missed recoveries for a 47,000-member Medicare Advantage plan by performing a second-pass audit behind a large national analytics vendor. Deep expertise and detailed claim scrutiny revealed opportunities the first-pass provider overlooked—returning significant value to the plan and its members.

Penstock found $4.8 million in potential savings for a Medicare Advantage health insurer by performing a meticulous second-pass post-payment audit—after seven incumbent vendors had already reviewed the same claims.

Penstock uncovered $400,000 in overpayments for a national health plan after identifying improper reimbursement for an unlisted laboratory procedure code—an error buried in contract language and adjudication rules. Advanced analytics paired with contract and coding expertise revealed the full scope of inappropriate payments and helped prevent future leakage.

Penstock uncovered $2.7 million in missed recoveries for a state Medicaid managed care plan by identifying duplicate same-day Emergency Department and Observation payments—an issue tied to a state policy gap that other vendors only partially detected. Penstock’s data mining and policy expertise revealed the full scope of overpayments from day one.