Medical Claims Audit Uncovers Over $80K in Costly Errors

Business Situation

A food and beverage industry employer, in collaboration with their employee benefits broker, partnered with BMI Audit to conduct a comprehensive medical claims audit after identifying significant errors in claims processing by their third-party administrator (TPA).

Solution

Using AUDiT iQ™, BMI’s proprietary claims auditing software, our expert team focused on:

  • Reviewing 100% of medical claims paid over two years.

  • Validating plan compliance, eligibility, and detecting fraud, waste, or abuse.

  • Conducting targeted claims audits based on data analysis.

  • Providing in-depth reports with cost-saving recommendations.

Audit Findings

  • Duplicate claim payments leading to unnecessary costs.

  • Failure to enforce third-party liability and subrogation policies.

  • Payments for ineligible procedures explicitly excluded by the health plan.

Audit Outcome

BMI’s audit identified over $80,000 in confirmed overpayments, exceeding the audit cost. The TPA acknowledged manual processing errors and initiated recovery efforts.

To prevent future medical claims processing errors, BMI assigned an advisor to help the employer hold the TPA accountable and implement claims auditing best practices for long-term cost containment.

Medical Claims Audit, Healthcare Claims AuditRobert Temples