Trust, but Verify – Annual Claims Audit Finds Mistakes Continue


Business Situation 

This organization engages BMI to conduct annual audits of medical claims paid by their third-party administrator to ensure claims are continuing to be paid correctly following their last audit.


Solution

Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:

  • Analyze 100% of all medical claims paid by the third-party administrator 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

Inadequate safeguards in place to prevent continued payment of non-covered services.

  • Duplicate payments

  • Incorrect application of copayments and plan limitations

  • Inconsistencies with proper coding, adjudication and reimbursement


Audit Outcome

The third-party administrator agreed to initial overpayment amounts exceeding $25,000 adding to a grand total of over $317,000 in overpayments across the last 3 annual audits.  At the close of the audit, BMI assigned a specialist to provide recommendations to resolve any further outstanding issues between the client and the third-party administrator.  

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