Claims Audit Confirms Questionable TPA Accuracy

Business Situation

A statewide professional organization in the banking industry contacted BMI after catching several medical claims processing errors by their third-party administrator (“TPA”). Since these mistakes were stumbled upon by accident, a request for a full claims audit was made to ensure all claims were being paid appropriately under the plan.

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 12-month period.

  • Test claims against plan compliance, eligibility, ( and areas of possible fraud, waste, or abuse.

  • Audit a sample of 100 claims based on the analysis, highlighting areas of higher concern.

  • Present detailed findings and specific cost-saving recommendations based on the data and audit results.

Audit Findings

  • Duplicate payments of other paid claims

  • Miscalculations and application of copays and deductibles

  • Payment for services excluded by the plan

  • Payment for claims of ineligible members (for dates of service after coverage ended)

Audit Outcome

The TPA agreed to overpayment amounts totaling over $65,000 and to run additional impact reports to identify any other claims impacted by the systemic issues uncovered. The TPA attributed many of the findings to an incorrect plan build and to adjust the plan setup.

At the audit’s conclusion, BMI assigned a specialist to walk through a variety of recommendations including additional short and long-term solutions to prevent these types of errors and other plan discrepancies from continuing to occur.

Medical Claims Audit, Healthcare Claims AuditRobert Temples