Case Studies

A Medicare Advantage plan partnered with Penstock to launch a CMS-compliant pre-pay inpatient review program — preventing $2.66M in improper payments in just 4.5 months with a 45.9% savings rate.

Penstock’s post-pay analysis uncovered high-volume claims activity that appeared to bypass existing authorization and validation controls, helping a health plan identify potential payment integrity gaps.

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.