Claims Audit Reduces Fiduciary Risk and Future Expenditures
Business Situation
Faced with potential increased scrutiny of fiduciary responsibility by the Department of Labor, this client engaged BMI to conduct an audit of their self-insured medical plan to demonstrate due diligence.
Solution
Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:
Review 100% of all claims paid during a two year period.
Test claims against Summary Plan Descriptions, contracts and eligibility records.
Identify and analyze areas of possible fraud, waste, and abuse.
Confirm appropriate coordination of benefits.
Audit a sample of claims on-site at the third-party administrator’s payment facility.
Present detailed findings in addition to specific cost-savings recommendations based on the data and audit results.
Provide post-audit guidance and assistance.
Audit Finding
Claims paid without appropriate coordination of benefits where other insurance was primary
Payment for non-covered services
Duplicate claims, improper coding and modifiers
Audit Outcome
Initial adjustment amounts due to incorrect adjudication totaled $30,000. A majority of the errors were attributed to auto adjudication where the processing system should have pended the claim for processor review. A dedicated Post-Audit Support Coordinator was assigned by BMI to coordinate resolution of the issues identified as a result of the audit.
Coinciding with the audit, BMI analyzed plan designs against the claims data resulting in over $250,000 in potential future savings by making suggested plan language revisions. Areas in the analysis contained observations where the plan is silent, lacking limitations or overly broad.