Repeat Claims Audits Produce over $200k in Savings

Business Situation

Since 2011, this city government has engaged with BMI to conduct regular, every other year, audits to verify the accuracy of medical claims paid by their third-party administrator (TPA).

Solution

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

  • Analyze 100% of all medical claims paid by the TPA during a two-year 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

  • Coverage provided for certain benefits specifically excluded by member plan documents

  • Failure to apply Medicare as primary where applicable, causing increased expenditures

  • Processing and reporting discrepancies between one of the client’s vendors and the TPA

Audit Outcome

The TPA agreed to initial overpayment amounts exceeding $27,000 which added to a grand total of over $200,000 saved since their first audit in 2011. Issues identified in the most recent audit were attributed to manual overrides, processing mistakes and incorrect plan builds.

At the conclusion of the audit, BMI assigned a specialist to walk through a variety of additional recommendations including additional short and long-term solutions to resolve and further prevent the opportunity for processing errors to occur.

Medical Claims Audit, Healthcare Claims AuditRobert Temples