Adjudication Inaccuracies Uncovered Through Claims Audit

Business Situation

To maintain fiduciary responsibility over health plan assets, an independent school district engaged BMI to conduct an independent audit of their third-party administrator’s (“TPA”) claims payments made on their behalf.

Solution

Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:

  • Analyze 100% of all medical claims paid by the TPA during an 18-month period.

  • Test claims against Summary Plan Descriptions, contracts and eligibility records.

  • Identify areas of possible fraud, waste, or abuse and confirm appropriate coordination of benefits.

  • Audit a sample of claims based on the analysis.

  • Present detailed findings and specific cost-savings recommendations based on the data and audit results.

Audit Findings

  • Systemic failure to apply correct copayments and deductibles for telehealth services

  • Incorrect claim processing leading to pricing errors

  • Identification of conflicting plan language (regarding 7 different benefit areas) between plan member documents and the TPA

Audit Outcome

At the audit’s conclusion, BMI assigned a specialist to walk through a variety of recommendations including additional short and long-term solutions to resolve and further prevent the opportunity for processing errors to occur.

The TPA agreed to initial overpayment amounts exceeding $56,000 and has initiated refund processes. Manual processor error was given as the cause for many of the identified issues.

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