Claims Audit Against Plan Design Reveals Inaccuracies

Business Situation

To ensure the accuracy of claims payments compared against their plan design, and to identify any other opportunities for cost containment, this large manufacturing and service provider engaged BMI to audit 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 24-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

  • Payment of non-covered benefits such as genetic testing, portions of infertility treatment and certain out-of-network telephone consults

  • Overpayment of COVID 19 lab tests

  • Failure to apply correct reduction on assistance surgeon charges

  • Duplicate claim payments

Audit Outcome

The TPA agreed to initial overpayment amounts exceeding $25,000 while continuing to dispute accuracy of $8,000 in additional potential errant payments identified through the audit.

At the conclusion of the audit, BMI assigned a specialist to walk through a variety of additional recommendations including both short-term and long-term solutions to resolve and prevent future claims processing errors from occurring.

Interested in learning more? Contact us.

Medical Claims Audit, Healthcare Claims AuditRobert Temples