Claims Audit Confirms COVID-19 Claim Adjudication Suspicions

Business Situation

An engineering firm with over 7,000 employees engaged BMI to conduct of medical claims adjudicated by their third-party administrator (“TPA”) after suspecting some COVID-19 claim related expenses were incorrect. 

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 an 18-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

  • Failure to apply CMS-issued COVID-19 pricing for certain CPT codes

  • Failure to cover COVID-19 testing at 100%, as instructed

  • Claim overpayments due to incorrect pricing, duplicate claims payments and incorrect coding

Audit Outcome

The TPA agreed to initial overpayment amounts close to $40,000 and to begin refund initiation processes and impact reports. The TPA cited manual claims processor errors as the root cause for many issues identified.

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

Healthcare Claims Audit, Medical Claims AuditRobert Temples