Finding Flaws and Recovering Misdirected Funds from a Third Party Administrator

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Finding Flaws and Recovering Misdirected Funds from a Third Party Administrator

An ICA Client, one of the nation’s largest Real Estate Investment Trusts, had sought ICA’s help clearing up claims information and confusion they had with the billing statements from their third party administrator. An audit was conducted at the TPA’s office of the claims’ files and serious flaws were found in the method of billing the Client. When a renewal policy from four years earlier changed the Self-Insured Retention Endorsement, no one at either the Client or the TPA, noticed that the TPA’s own fees were moved from “outside the retention” to “within the retention”. This effectively meant that for any claim that reached the retention level of a certain amount per claim, the TPA’s fees thereafter had to be paid not by the Client any longer, but should have begun to be paid directly by the insurance company. This Client owned numerous indoor malls and strip malls, and thus suffered from hundreds of slip and fall type claims every year. The number of claims reaching the retention level since the change in this policy form numbered about fifty, and thus for each of these claims the Client had been overbilled. ICA interceded on the Client’s behalf to convince the TPA that it must repay the amount overbilled on its own fees where they were paid both by the Client and by the insurance company for their fees. ICA also worked with both the Client and the TPA to prevent any future similar errors, to place a cap on the TPA’s future fees on a per claim basis, and to establish a line of communication with the insurer, the TPA, and the Client to work through any future billing questions. ICA’s claims audit service was adopted by the Client on a permanent basis going forward annually. See ICA’s Audit Service of Third-Party Administrators.

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