Move to Self-Insured Medical Plan Prompts Beneficial Audit

Business Situation

A nationally recognized mobile application developer engaged BMI to audit medical claims paid by their third-party administrator (“TPA”) after moving to self-insured and making several plan design changes.

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 12-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

  • Discrepancies over which services required pre-authorization.

  • Provider reimbursements exceeding actual charged amounts.

  • Duplicate claim payments.

  • Ambulance transfers despite no correlating facility claims from the hospital that the participant was transferred to.

Audit Outcome

The TPA agreed to initial overpayment amounts exceeding $29,000 while continuing to dispute the accuracy of over $100,000 in additional questionable payments. The TPA committed to review their processes for prior authorization and changing other aspects of claims processing uncovered by the audit. 

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

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