The Benefits of Conducting an Implementation Audit Prove True for BMI Audit Services
As organizations strive to provide comprehensive healthcare benefits, the successful launch of a new or changing healthcare benefits plan is crucial. One often overlooked but essential aspect of this process is an implementation audit and what better way to show its value than to use our own product?
BMI recently made significant changes to our medical plan and wanted to ensure that employees would receive benefits as designed and communicated to them.
As a result of the implementation audit, we were able to:
clarify plan intent:
Plan documentation was silent on how outpatient clinic visits should be managed for non-mental health providers and testing showed inconsistencies with how these services are being processed. BMI was able to clarify the plan’s intent to ensure services are provided as intended.
fix errors and prevent unnecessary expenses:
Sixteen scenarios were identified as being set up incorrectly within the TPA’s system. These benefits were adjusted and then confirmed to be programmed correctly by the end of the audit, thus, avoiding any negative impact on plan members and/or BMI as the plan sponsor.
Would have cost the plan money:
Non-emergency care provided in the ER was not applying the $250 copay before being applied to the deductible and coinsurance.
Two CPT codes for genetic testing were being identified as diagnostic which resulted in services for genetic testing being processed without a maximum calendar year benefit as outlined in the plan documentation.
Routine hearing exams were being covered at 100% rather than applying to the deductible and coinsurance. The Administrator confirmed a system limitation as it cannot be set up to process per the plan design and is now flagged for manual processing
In-network cognitive therapy was not applying the $20 copay, nor did it have a calendar year limit of 36 visits set up. Instead, testing showed that this benefit was set up to apply to the deductible and coinsurance only.
Out-of-network cognitive therapy was not set up with a calendar year limit of 36 visits. Instead, testing showed that this benefit was only set up to apply coinsurance and the deductible.
The visit count accumulator did not include all Home Health Services, so it was not tracking the 120-calendar year visit maximum correctly.
Charge reductions of $500 were applied twice (rather than once) on a single claim for retro-authorizations on Home Health Services.
The skilled nursing accumulator was not tracking to the 120 days per calendar year maximum correctly as a claim with 5 days of service counted as 1 day towards the accumulator.
Multiple cosmetic surgery scenarios were being covered as they were not properly set to deny or pend for review.
Elective Abortions were not set up to exclude.
A $20 copay was not set to apply nor was the accumulator towards a calendar year limit of 36 visits tracking correctly on pulmonary therapy.
Would have cost the member money:
Oral surgery for removal of soft tissue/bony impacted teeth was set to exclude rather than be covered at 100%.
Non-routine hearing services for adults were set up to deny and apply to the deductible and coinsurance, rather than be covered at 100%. The Administrator confirmed a system limitation as it cannot be set up to process per the plan design and is now flagged for manual processing.
Obesity was set up as a non-covered benefit, rather than covered with a $5,000 calendar year maximum.
Out-of-network deductibles and maximums were not set up to cross-apply to credit in-network deductibles and maximums.
Residential Treatment was charging a $20 copay rather than applying solely to the deductible and coinsurance.
Thanks to the implementation review, BMI was able to identify and rectify potential costly mistakes. This helped prevent future issues for all stakeholders including ourselves, our members, and the TPA. Fortunately, the testing was conducted early enough, and no claims required any adjustments.
Additional, non-quantifiable benefits to conducting an implementation audit include:
alignment with organizational intent
An implementation audit allows for an in-depth review of how benefits are delivered to members to ensure alignment with unique plan intent. This alignment ensures that the healthcare benefits plan becomes a strategic asset that supports the organization's mission and vision.
employee satisfaction and engagement
An implementation audit ensures that the plan is providing benefits as communicated by the plan sponsor and helps to identify any potential issues that may hinder employees from fully utilizing benefits. A satisfied and engaged workforce not only contributes to a positive work environment but also enhances overall productivity while also boosting employee satisfaction, engagement, and loyalty.
continuous improvement
An implementation audit is not a one-time event but rather a continuous process. By regularly testing benefits as changes are made or when moving to a new TPA, organizations can identify issues and respond proactively. This iterative approach ensures that the benefits plan remains relevant, competitive, and resilient in the face of evolving healthcare landscapes and employee expectations.
In the complex realm of healthcare benefits, an implementation audit is a valuable tool for organizations seeking to enhance their employee offerings. From ensuring compliance to aligning with organizational goals, and fostering employee satisfaction, the benefits of a thorough implementation audit are multifaceted. Investing time and resources in this critical evaluation process not only safeguards the organization but also paves the way for a healthier, happier, and more engaged workforce.
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