Financial errors more than $25K
For the month of June, BMI is pleased to present a recent finding from one of our dental claims audits.
Audit Issue
Benefits were paid for simple restorative dental services despite plan language clearly stating that “no benefits will be paid for treatment of teeth, gums, or tooth-related services regardless of age, mental, or physical conditions of the patient, unless such treatment is accident-related”.
TPA Response
The administrator cited its standard internal administrative policy to pay certain dental benefits on the basis of “age exemption and/or presence of a medical condition”.
Audit Finding
The exclusion language for this self-insured plan was exceedingly clear that age and medical conditions were not to be considered in the determination of benefits; however, the TPA’s automated claims payment system was not programmed to recognize a non-standard benefits exclusion.
Financial Error
The administrator agreed to financial errors of more than $25,000.