Claims Examiner Mistakes Exist Despite Technology and Automation
Business Situation
This global research and manufacturing organization engaged BMI to audit medical claims paid by their third-party administrator to ensure claims were being processed correctly for plan participants.
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 12 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
Incorrect application of copayments, deductibles and out of network benefits
Failure to follow plan exclusionary language for cosmetic services
Duplicate payments and overpayments
Plan visit limitations not applied to certain therapies
Audit Outcome
The third-party administrator agreed to overpayment amounts exceeding $50,000 while continuing to dispute the accuracy of other payments. The third-party administrator attributed many errors to claims examiner mishandling and committed to provide additional training. Additional impact reports were also requested to examine 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.