Claims Audit Reveals Plan Build Mistakes and Processor Errors

Business Situation

A large manufacturer engaged BMI to audit medical claims paid by their third-party administrator (“TPA”) after concerns were raised about whether certain claims were being paid appropriately.

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 a 24-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

  • Incorrect setup during initial plan build resulting in payment of various excluded services

  • Failure to obtain prior authorization when required

  • Contradictions between the TPA’s clinical policy vs. the client’s Summary Plan Description

  • Separate services billed and reimbursed at a higher rate when already part of another service

Audit Outcome

The TPA agreed to initial overpayment amounts exceeding $40,000 and to run impact studies to identify additional claims affected by some of the systemic issues discovered through the audit.  The TPA committed to conduct additional claims processor training and correct portions of the plan build to prevent errors occurring in the future.

At the conclusion of the audit, BMI assigned a specialist to walk through a variety of additional recommendations including both short-term and long-term solutions to resolve and prevent future claims processing errors from occurring.

Contact us to learn how a medical claims audit can help your business.

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