Over $200k in Mistakes Uncovered by Claims Audit

Business Situation

A Native American Organization with over 9,000 enrolled members engaged BMI to audit and verify the accuracy of medical and prescription drug claims paid their third-party administrator (“TPA”) and pharmacy benefits manager (“PBM”).

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 during an 18-month period.

  • Test claims against plan compliance, eligibility and areas of possible fraud, waste, or abuse.

  • 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

  • Payment for claims related to a plan member’s child who was never enrolled in the plan

  • Duplicate payments of other paid claims

  • Failure to apply coordination of benefits where members had other primary insurance

  • Payment for drugs excluded by the plan

Audit Outcome

The TPA agreed to overpayment amounts totaling over $200,000 and to begin overpayment collections and reprocessing with providers. The TPA acknowledged several major findings without attributing a root cause.

 At the audit’s conclusion, BMI assigned a specialist to walk through a variety of recommendations on how to hold the parties accountable, including additional solutions to prevent these types of errors from continuing to occur.

Healthcare Claims Audit, Medical Claims Audit, Pharmacy Claims AuditRobert Temples