Following the Claims Dollars Leads to Confirmation of Client’s Suspicions

Audit Issue

Our client engaged us to conduct an audit of their medical claims administrated by their third-party administrator.  The client suspected a variety of claims processing errors including incorrect coding, copays, and duplicate claims over the course of a two-year period.

Audit Finding

Using a combination of our proprietary software AUDiT iQ™ to review of 100% of all claims paid during the audit period and an on-site visit to the administrator, BMI confirmed the following types of errors: 

  • Laparoscopic procedures billed without required primary procedures

  • In-network co-pays processed as out-of-network co-pays

  • Duplicate payments for same facility services

  • Unbundling (billing components of a service/procedure separately when they should one)

Third-Party Administrator Response

Directly following the on-site visit, the third-party administrator agreed to the errors without question.  The administrator also agreed to address inadequacies in their claims processing software and internal adjudication policies.
 

Audit OutcomE

This audit finding identified over $50,000 in claims processing adjudication errors leading to additional ad-hoc reporting to quantify the overall financial impact of the errors.  A credit for the amount of these errors was requested and applied.  A subsequent audit is being planned to ensure compliance with corrective actions.

Audit Finding of the M..., AUDiT iQ, duplicate payments, Medical Claims Audits, Third-Party AdministratorRandy Light, Founder + Executive Advisor