Medical Claims Audit Leads to Path of Corrective Action and Savings
Audit Issue
To help curb the trend of rising health care costs and to clarify benefit plan intent, BMI was engaged to audit our client’s medical health plans every two (2) years.
Audit Finding
Utilizing our auditing software AUDiT iQ™, our system electronically analyzed 100% of the claims data to flag potential errors. Our auditors then reviewed the electronic findings, eliminated any false positives and choose samples representative of the entire population across a wide range of error categories and dollar amounts. Following our on-site visit, the administrator agreed to the following errors:
Cosmetic procedures such as removal of skin tags and varicose veins were paid without documentation of medical necessity.
Payments were made for non-covered dental services and supplies.
Botox injections were paid without documented approval and review.
Standard payment adjustment rules for an assistant at surgery were not applied to the correct CPT codes.
Carrier/Third-Party Administrator Action and Response
The claims administrator agreed to reimburse the plan for the payment errors were made and set a clear path of corrective actions with the client to prevent future losses. Shortly after the conclusion of the audit, the administrator assigned the client to more experienced account team.
Financial Error
The overall effect of agreed-to payment errors amounted to a little over $40,000.