Claims Audit Uncovers Thousands in Manual Errors
Business Situation
A leading global medical technology company engaged BMI to audit medical claims paid by their third-party administrator as part of their due diligence efforts.
Solution
Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:
Analyze 100% of all medical claims paid by the third-party administrator during a 16-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
Payments issued for excluded benefits such as elective abortion, biofeedback, dental extraction services, select durable medical equipment, select infertility services, orthotics, and services to correct vision.
Plan visit or dollar limitations were not correctly applied to chiropractic services, hearing aids and speech therapy.
Audit Outcome
The third-party administrator agreed to initial overpayment amounts exceeding $48,000 while continuing to dispute the accuracy of other $60,000 in other payments. The third-party administrator attributed the costliest mistakes to manual errors by claims examiners. Additional impact reports were also requested to reveal the full extent of issues identified through the audit.
At the conclusion of the audit, BMI assigned a specialist to provide recommendations to resolve any further outstanding issues between the client and their third-party administrator.