Comprehensive Audit of Medical Claims Uncovers Errors
Business Situation
In support of due diligence efforts, a construction industry health and welfare fund approached BMI to conduct a comprehensive audit of 24 months of medical claims paid by their third-party administrator.
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 24 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 medical claims based on the analysis.
Present detailed findings and specific cost-savings recommendations based on the data and audit results.
Provide guidance and assistance post-audit.
Audit Findings
Providers overcharged when coding existing patient visits with new patient codes.
Plan exclusionary language not followed for family counseling or genetic testing.
Coordination of benefits not applied correctly with Medicare.
Audit Outcome
The third-party administrator agreed to initial overpayment amounts exceeding $30,000, to adjust incorrect medical claims accordingly and run additional impact reports to determine the extent of issues uncovered by the audit.Following release of the findings, BMI assigned a specialist to help facilitate any further corrective actions and resolve any outstanding issues identified between the client and their third-party administrator.
Learn more about medical claims audit solutions here.