Health Plan Inaccuracies Uncovered Through Claims Audit

Business Situation

A statewide association of legal professionals contacted BMI to perform an audit of medical claims paid by their third-party administrator (“TPA”) and verify the accuracy of claims paid on their behalf.

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 claims based on the analysis.

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

Audit Findings

  • Surgery claims processed without the member’s listed primary insurance

  • Failure to obtain required prior authorization for certain procedures

  • Payment for services not covered by the plan

  • Incorrect pricing leading to overpayments

Audit Outcome

The TPA agreed to initial overpayments totaling over $25,000, to run impact reports to identify additional claims impacted by the issues uncovered and institute correction actions. Errors were attributed to manual processor adjustments and system misconfigurations.

An additional nearly $32,000 in incorrect payments in which the TPA disagrees with were also identified. The association will review and determine with the TPA if any corrective steps are necessary.

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