Pre-Implementation Audit Uncovers Hidden Discrepancies

Business Situation

A client within the financial services industry approached BMI to conduct a pre-implementation audit after moving to a new carrier. Their primary objective was to verify whether the carrier’s system was set up appropriately to administrate their claims according to plan benefits. 

Solution

After reviewing plan documentation, auditors selected and customized 375 test claims across the client’s 6 health plans covering a variety of claims scenarios including limitations, exclusions, deductibles and out-of-pocket maximums.  Accuracy testing was conducted via WebEx over the course of a week with the carrier.

Audit Findings

Over 20 inconsistencies between plan documentation and system setup were discovered which included items such as:

  • Visit limitation discrepancies for chiropractic, home health care and inpatient rehab services

  •  Out-of-network dialysis paid at 100% vs. 60% after deductible

  • Multiple copayment, coinsurance and deductible discrepancies for in and out-of-network benefits

Audit Outcome

Through this independent testing,  this client was able to catch potential costly mistakes and avoid future claims adjudication headaches.  The carrier ran impact reports and corrected some findings identified during the audit while others need further verification by the client on the intended benefit and subsequent plan language revisions.

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Audit Finding of the M..., BMI Audit Services, claims administrator, cost-containment solution, health care benefits a..., health care claims, health plan audit, internal audit department, Medical Claims Audits, payment errors, pre-implementation auditRobert Temples