Audit of Plan Intent Leads to Corrective Actions
Business Situation
To ensure plan compliance after making several plan changes, this client chose to conduct a claims audit of their administrator for their self-insured medical plan.
Audit Finding
Using a combination of our proprietary software AUDiT iQ™ and the expertise of our audit staff to analyze 100% of the claims, BMI identified some of the following exclusions within 15 different audit categories:
Payment for expenses related to pregnancy of a dependent child (excluded)
Payment for acupuncture and massage therapy as part of a chiropractic visit (excluded)
Payment for family counseling (excluded)
Payment for more than 1 sonogram for routine pregnancy (excluded)
Third-Party Administrator Response
The claims administrator agreed that claims for services specifically excluded by the client’s plan were paid in error. They also agreed to run impact reports to help assess the overall financial impact of those errors.
Audit Outcome
At the conclusion of the audit BMI assigned a Post-Audit Support Coordinator to walk the client through the audit findings and provide steps to obtain resolution to the identified errors. At the client’s directive, BMI worked with the administrator to ensure all future claims would be paid in strict accordance to the client’s plan documents.
In addition to errors identified and corrected directly through the audit, BMI’s analysis of plan design and claims data identified an additional $349,000 in potential future savings by making suggested plan language revisions.