Combining advanced technology with time-tested audit methodologies, BMI has developed an innovative approach to assessing health care claims administrative effectiveness.

After completing a thorough manual review of plan descriptions, contracts, administrative agreements, and other relative plan materials, we build detailed plan-specific profiles to be used by AUDiTiQ.  Using electronic claims transaction data provided by the claims administrator, AUDiTiQ comprehensively evaluates reported diagnosis and procedure coding details, patient eligibility, and appropriateness of treatment relative to the plan’s coverage, limitations, or exclusions of services.  Unlike some companies using proprietary electronic audit technology, we do not simply produce a listing of implied errors, collect our fees, and declare the audit a success. 

AUDiTiQ helps us to eliminate from the sampling population those claims with a high likelihood of correct payment.  Because the size of a validation sample may be limited to accommodate the administrator’s business resources, our experience, knowledge, and professionalism is the key to selecting quality samples from the remaining population.  While on-site at the claims administrator’s facility, we review physical records and documents relied upon by the administrator in support of their benefit payment decisions.  An open dialogue between the auditors and the administrator is maintained throughout the audit process.

This emerging audit methodology is efficient and cost-effective focusing on opportunities for corrective action while not ignoring opportunities for recovery of errant payments.

A detailed, easy-to-use report of audit findings is prepared by BMI, and serves as the foundation for the development of realistic, practical, and cost-saving solutions.