Pre-Implementation Audit Prevents Costly Mistakes

Business Situation

This communications sector client with 3,500 employees approached BMI to conduct a pre-implementation audit after a segment of the company was carved out and paired with a new third-party administrator (“TPA”) for their health plans. The primary objective was to confirm that the new TPA’s system was set up appropriately according to each plan’s stated benefits. 

Solution

After reviewing plan documentation, auditors selected and customized over 800 test claims across the client’s 3 health plans. These test claims covered a variety of claims scenarios including limitations, authorizations, exclusions, deductibles and custom benefits. Accuracy testing was conducted remotely with the TPA over the course of a week.

Audit Findings

Twenty-seven (27) inconsistencies between plan documentation and system setup were discovered, including items such as:

• Deductibles and coinsurance not applied correctly to some out-of-pocket maximums

• Certain covered benefits incorrectly programmed to be denied

• In-network virtual visits paid at 100% despite copay or deductible requirements

• Certain benefit accumulators did not apply to the stated visit limitation.

• Failure to apply penalties correctly for benefits provided without required prior authorization

Audit Outcome

Through this independent testing, the client was able to catch and prevent future costly mistakes while ensuring accuracy for their health plan members. Many findings created an opportunity for the client to clarify the intended benefit and instruct the TPA to make subsequent plan or programming changes which will prevent errors in claims processing for plan members in the future.