Internal Audit Department Partners with BMI
Audit Issue
Our client’s internal audit staff wanted to partner with an audit firm who enabled their department to have hands-on involvement throughout the medical claims audit process. BMI’s auditors routinely allow our clients to accompany them onsite when reviewing our audit samples and in this case, allowed the employer’s internal audit staff to help select audit samples at our office to review prior to the onsite visit.
Audit Finding
Three (3) audit samples reviewed onsite revealed that:
Standard payment adjustment rules for multiple procedures were not applied correctly to the CPT code.
The employee’s spouse had other insurance that would have been primary for the dependent children.
The surgeon and assistant surgeon were each allowed the same rates when the assistant should have been paid no more than 20% of the surgeon’s allowance.
Third-Party Administrator Response
The administrator agreed to the errors and immediately provided refunds to our client. They also agreed to perform an impact analysis to determine the total financial impact of potential similar errors.
Financial Error
The total amount of errors on just the three (3) audit samples above totaled over $10,000 in addition to $7,000 in unrelated errors agreed to by the 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