Claims Audit Uncovers Manual Errors Costing Thousands

Business Situation 

This client’s employee benefits broker approached BMI for reassurance of proper plan adjudication after their third-party administrator reimbursed the group for errant claim payments.

 

Solution

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

  • Analyze 100% of all medical and prescription drug claims paid by the third-party administrator 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.

  • Provide guidance and assistance post-audit.

 

Audit Findings

  • Incorrect pricing and reimbursement calculations.

  • Duplicate payments for services provided.

  • Inconsistencies with proper copay and deductible allocation.

  

Audit Outcome

The third-party administrator agreed to initial overpayment amounts exceeding $45,000 and implement further processor training to the claims team where manual errors were identified.  Following release of the findings, BMI assigned a specialist to help facilitate any further corrective actions and resolve any outstanding issues identified between the client and their third-party administrator.

Coinciding with the audit, BMI analyzed plan designs against the claims data to identify over $160,000 in additional potential future savings by making suggested plan language revisions to consider going forward. Areas in the analysis contained observations where the plan is silent, lacking limitations or overly broad.

audit samples, AUDiT iQ, BMI Audit Services, claim audit, claims administrator, claims audit, cost-containment solution, claims data, retrospective audit, Self-Insurance Programs, Third-Party Administrator, TPA auditRobert Temples