Since 2011, our Audit Finding of the Month provides insights into what drives BMI to help organizations uncover who and what their healthcare dollars are being spent on.
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”).
A labor union engaged BMI to verify the eligibility of 1,047 health plan dependents, ensuring compliance and reducing costs. BMI provided bilingual support, managed documentation securely, and identified 51 ineligible dependents, removing them from coverage. The audit led to $357,000 in annual savings and achieved a 2,356% ROI by eliminating ineligible enrollees.
An employer in the manufacturing industry with over 450 employees engaged BMI to audit and verify the accuracy of medical and prescription claims payments. Both the medical and pharmacy claims audits identified errors related to claims processing, including payment for ineligible services and systemic administrative issues. The TPA agreed to overpayment amounts totaling over $70,000 and to run additional impact reports to identify any other claims impacted by the systemic issues uncovered. Follow-up audits are recommended for both areas to monitor progress and minimize financial risk.
A consortium of regional school districts working together to save taxpayer dollars engaged BMI to verify the eligibility of 3,735 total spouses and children on their health plans. Plan eligibility rules contained a “working spouse” provision which meant any of the 1,207 spouses who had other coverage available to them through employment were ineligible.
An employer in the automotive industry with over 10,000 employees engaged BMI to audit and verify the accuracy of medical claims paid by their third-party administrator (“TPA”). The employer had not previously conducted an audit despite being with the TPA for several years.
The school district realized that they do not request proof from employees to confirm dependent eligibility during enrollment, which poses a potential risk. As a result, BMI was engaged to verify the eligibility of 1,599 dependents on their medical plans before the next open enrollment.
An organization in the banking and financial industry asked BMI to verify the eligibility for 1,181 enrolled dependents on their medical plans. Previous checks by BMI in 2016 and 2019 resulted in the removal of 71 ineligible dependents, saving over $250,000.
