Case Studies

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.