Case Study Summary: 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.

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Penstock conducted a detailed analysis of a regional Health Plan’s medical claims to evaluate compliance with the applicable requirements of NYS HCRA. Our evaluation focused on regulatory and NUBC changes and cross-claims analysis to identify exclusions currently missed based on stand-alone claim determinations.

In addition to identifying and recovering inappropriately submitted HCRA funds, Penstock was able to provide coding and billing guidance, industry-standard policies and guidelines, and the applicable regulatory references that support operational or system changes required to ensure the accuracy of assessment obligations.

Penstock identified $2,963,502 in surcharge overpayments for the time period under review. By providing the reference documentation and recommendations, the client was able to make systemic changes to prevent future recurrences.

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