Claims Audit Uncovers Thousands in Manual Errors
Business Situation
A leading global medical technology company engaged BMI to audit medical claims paid by their third-party administrator as part of their due diligence efforts.
Solution
Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:
Analyze 100% of all medical claims paid by the third-party administrator during a 16-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
Payments issued for excluded benefits such as elective abortion, biofeedback, dental extraction services, select durable medical equipment, select infertility services, orthotics, and services to correct vision.
Plan visit or dollar limitations were not correctly applied to chiropractic services, hearing aids and speech therapy.
Audit Outcome
The third-party administrator agreed to initial overpayment amounts exceeding $48,000 while continuing to dispute the accuracy of other $60,000 in other payments. The third-party administrator attributed the costliest mistakes to manual errors by claims examiners. Additional impact reports were also requested to reveal the full extent of issues identified through the audit.
At the conclusion of the audit, BMI assigned a specialist to provide recommendations to resolve any further outstanding issues between the client and their third-party administrator.
Explore All Blog Categories
- ASO
- AUDiT iQ
- Affordable Care Act
- Audit Finding of the M...
- BMI Audit Services
- CPT code
- Dependent Eligibility ...
- ERISA
- Ineligible Dependent A...
- Medical Claims Audits
- Sarbanes-Oxley
- Self-Insurance Programs
- Smart Business
- Spousal surcharge audit
- TPA audit
- Third-Party Administrator
- Uncategorized
- Value Forward
- audit samples
- claim audit
- claims administrator
- claims audit
- claims data
- cost-containment solution
- dependent audit
- dependent verification...
- drug exclusion
- duplicate payments
- durable medical equpment
- eligibility
- eligible dependent
- enrollment
- financial guarantee audit
- health care benefits a...
- health care claims
- health plan audit
- internal audit department
- medical and prescripti...
- on-site rebate audit
- ongoing dependent elig...
- payment errors
- pbm
- pharmacy benefits manager
- plan eligibility
- pre-implementation audit
- prescription drug clai...
- prior authorization
- re-enrollment audit
- retrospective audit
- routine pregnancy