Claims Administrator Payment Errors Exceed 160k

Audit Issue

BMI was engaged to fulfill our client’s fiduciary responsibility to ensure its health plans were being administered in accordance with the Summary Plan Description and other compulsory directives.

Audit Finding

Using Audit iQ to complete our forensic analysis of claims data, we selected claims for on-site review.  The following types of errors were confirmed:

  • Services not appropriate for the age of the member were paid.

  • Numerous duplicate payments were made.

  • Payments were made for various non-covered services.

  • Documentation of the first date of dialysis for end stage renal disease was not obtained. Without such documentation, the date on which Medicare becomes the primary payer may never be known.

Third-Party Administrator

The claims administrator agreed that multiple payment errors were made, various system edits were not in place and additional claims processing software would be purchased immediately.

Financial Error

The overall effect of agreed-to payment errors amounted to more than $160,000.

Audit Finding of the M..., claim audit, claims administrator, claims audit, duplicate payments, health care benefits a..., health care claims, Medical Claims Audits, Third-Party Administrator, TPA auditRandy Light, Founder + Executive Advisor