BMI Audit Finding of the Month: Multiple Claims Paid in Error Due to Systemic Flaw

Audit Issue

The audited health plan specifically excluded services relating to pregnancy of a dependent child except for complications of pregnancy.

Audit Finding

Multiple claims were identified as being paid for excluded routine pregnancy services.

TPA Response

The claims administrator agreed that claims were paid in error. In investigating the root cause of the error, they discovered a systemic flaw stemming from the plan’s allowance for complications. Apparently, the exception criteria were set up too broadly to automatically deny even routine services.

Financial Error

The administrator agreed to recoverable financial errors of more than $79,000.

Audit Finding of the M..., BMI Audit Services, Dependent Eligibility ..., health care claims, routine pregnancy, systemic flawRandy Light, Founder + Executive Advisor