Dependent Verification Identifies Ineligible Relationships

A city government was exploring several options to keep healthcare benefit costs from increasingly unnecessarily and engaged BMI to verify the eligibility of 1,495 dependents enrolled in the group’s health plans.

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Claims Audit Confirms Questionable TPA Accuracy

A statewide professional organization in the banking industry contacted BMI after catching several medical claims processing errors by their third-party administrator (“TPA”). Since these mistakes were stumbled upon by accident, a request for a full claims audit was made to ensure all claims were being paid appropriately under the plan.

Size Doesn’t Matter When Verifying Dependent Eligibility

A small manufacturer and exporter of recycled materials contacted BMI to verify the eligibility of 84 enrolled dependents on the group’s health plans.

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Health Plan Inaccuracies Uncovered Through Claims Audit

A statewide association of legal professionals contacted BMI to perform an audit of medical claims paid by their third-party administrator (“TPA”) and verify accuracy of claims paid on their behalf.

Due Diligence Claims Audit Uncovers Major Systemic Issues

A large insurance pool of educators consisting of over 10,000 employees contacted BMI to perform an audit of claims paid by their third-party administrator (“TPA”). The primary reason for the audit was because the TPA moved to a new platform for claims processing and no prior audits were ever conducted.

12,500+ Prescriptions Impacted by PBM Mistake

This nationally recognized electronics and technology company engaged BMI to conduct a pharmaceutical audit of their prescription drug plan and pharmacy benefit manager (“PBM”) to ensure claims were being processed correctly.

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Failure to Apply Appropriate Discounts Cost Employer $65k+

Audit reveals $77,000+ in overpayments while reviewing just 245 sampled medical claims. A large portion of the findings (just over $66,000) were due to the TPA failing to apply appropriate discounts. As a result of the audit, the TPA has agreed to run impact reports which will identify additional claims with overpayments caused by this same issue.

Demonstration of Health Plan Fiduciary Duty Achieves Success

A city government with 7,000 employees engaged BMI to conduct an independent audit of claims paid by their third-party administrator (“TPA”). The primary reason for the audit was to help demonstrate fiduciary responsibility over the plan’s benefits and expenses on behalf of participants

Pharmaceutical Audit Reveals over $500,000 in Errors

This major metropolitan hospital engaged BMI to conduct a pharmaceutical audits of their prescription drug plan and pharmacy benefit manager (“PBM”) to ensure claims were being processed correctly.

Dependent and Spousal Surcharge Verification Saves Money

A food and beverage retailer with 709 employees engaged BMI to verify whether any of the 1,383 enrolled dependents met the plan’s eligibility and spousal surcharge criteria.

Claims Audit Confirms Employer’s Suspicions of TPA Accuracy

A statewide association of financial institutions engaged BMI to conduct an audit of their member’s medical claims paid by their third-party administrator (“TPA”). The association reported higher than expected costs and claimant activity with suspicion of various claims processing issues.

Pre-Implementation Audit Prevents Costly Mistakes

This communications sector client with 3,500 employees approached BMI to conduct a pre-implementation audit after a segment of the company was carved out and paired with a new third-party administrator (“TPA”) for their health plans. The primary objective was to verify whether the new TPA’s system was set up appropriately according to each plan’s stated benefits.

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Recurring Pharmaceutical Audit Continues to Prove Beneficial

For over 10 years, this large public school district has engaged BMI to conduct annual pharmaceutical audits of their prescription drug plans and pharmacy benefit manager (“PBM”).

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Claims Audit Confirms COVID-19 Claim Adjudication Suspicions

An engineering firm with over 7,000 employees engaged BMI to conduct of medical claims adjudicated by their third-party administrator (“TPA”) after suspecting some COVID-19 claim related expenses were incorrect.

Adjudication Inaccuracies Uncovered Through Claims Audit

As a result of this medical claims audit, the plan’s 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.

Repeat Claims Audits Produce over $200k in Savings

Since 2011, this city government engages BMI to conduct biennial audits to verify the accuracy of medical claims paid by their third-party administrator (“TPA”).

Eligibility Verification Finds Unreported Employee Divorces

A school district with 259 employees approached BMI to conduct a dependent eligibility audit after discovering that an employee’s ex-spouse was incurring costs on their health plans.

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Claims Audit Reveals Underlying Issues

The TPA agreed to initial overpayment amounts exceeding $5,000, however, further investigation of claims samples by the TPA revealed an additional $150,000 in errant claims outside of those sampled through the audit.

Over $180,000 Saved Following Ineligible Dependent Removal

A manufacturer with 358 employees approached BMI to conduct a dependent eligibility audit after suspecting ineligible dependents were enrolled on the plan causing costs to increase unnecessarily.

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Pre-Implementation Audit Prevents Costly Mistakes

A client within the healthcare sector approached BMI to conduct a pre-implementation audit after deciding to consolidate two different existing plans with a single third-party administrator (“TPA”) in order to verify whether the TPA’s system was set up appropriately according to each plan’s benefits.

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