How does it work?
AUDiT iQ™ is a health care claims auditing software designed to efficiently and effectively identify errant payments. Users include: Insurance Carriers, Third Party Administrators, Self-paying Employers, Employers, and Employee Benefit Consultants/Brokers. You can read more about our Audit IQ on our blog.
Engine – FiLTER iQ is an intelligent and highly selective software analytical engine that can interpret and process benefit design logic. FiLTER iQ is the foundation for AUDiT iQ™’s modules: Medical, Dependent Eligibility, Prescription, and Dental.
When plan benefit designs are configured into AUDiT iQ™, the configurations are saved and available for editing, copying, and/or re-use for any subsequent audits.
Functionality is included to import, verify, and cleanse claims data. In addition, data mapping definitions are always saved so that they may be used for future audits.
A comprehensive set of pre-configured reports are available for use throughout the AUDiT iQ™ audit cycle. Reports can be generated against original claims data or after the claims selection process has been made.
AUDiT iQ™ has extensive customization capabilities that allow you to create your own categories, codes, and audit metrics tailored to your environment. Your staff can work with BMI personnel to customize existing modules or to create brand new modules specifically tailored to your auditing requirements.
Modules in Audit IQ
The medical module is capable of auditing all aspects of a medical health plan and its associated claims data. A comprehensive set of medical codes are included with the software and are fully integrated into the auditing process.
These code sets include: AMA CPT®, AMA HCPCS, AMA ICD-9, and CMS Revenue codes. The Medical module is based on over 80 categories that have been pre-tuned and configured out-of-the-box to use the most appropriate medical codes available. In addition, each category can be configured to capture benefit design metrics related to deductibles, co-insurance, in-network / out-of-network payment levels, dependents, maximums based on occurrences or incidents, and others.
Some examples of audit categories include:
Potential Other Party Liability
Excluded Services (acupuncture, cosmetic procedures, . . .)
Limited Services (chiropractic, physical therapy, . . .)
The Rx module is tailored for pharmaceutical claims. Categories have been created to effectively audit many aspects of any pharmaceutical benefit plan including co-pays, exclusions, limitations, AWP and MAC pricing discounts, as well as other criteria. It utilizes both historical and current databases published by First Data Bank to define the Rx categories and assist with the analysis of the claims data.
Dependent Eligiblity Module
The Dependent Eligibility module is designed to accept various plan eligibility criteria and use those factors, along with the eligibility data, to build the communications / mailings, track each employee response, and report those responses in a real-time tabular or graphical manner.
The Dental module comes pre-configured with categories that effectively audit dental claims. Using the American Dental Association’s Current Dental Terminology (CDT) code set, AUDiT iQ™ can intelligently assess benefit design metrics related to co-insurance, exclusions, deductibles, maximum benefits, and others.