Case Studies

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.

Penstock partnered with a large New York not-for-profit health plan to assess compliance with NYS Public Health Law §2807 (HCRA) across claims from 2014–2020, uncovering more than $60M in surcharge overpayments. Through membership file analysis, claim-level validation, exemption verification, and regulatory documentation review, Penstock enabled full recovery and established ongoing retrospective and prospective audits to ensure long-term HCRA accuracy.

Penstock analyzed a regional health plan’s medical claims to assess compliance with NYS HCRA requirements and uncovered nearly $3M in misallocated surcharge payments. By identifying exclusions missed in stand-alone claim determinations and providing coding, billing, and regulatory guidance, Penstock enabled the plan to recover the funds and implement system changes to prevent recurrence.

Penstock’s proof-of-concept audit for a national health plan uncovered clinically inconsistent swings in billed units for a wound-care skin substitute billed per square centimeter. By benchmarking utilization against clinical norms and tying unit variability to the plan’s percent-of-charge carve-out methodology, Penstock revealed hidden overpayments that standard workflows had not detected.