Retail Employer Identifies $28K+ in Overpaid Medical Claims

Business Situation

A major employer in the retail industry, alongside their employee benefits consultant, partnered with BMI Audit Services to audit and verify the accuracy of medical claims processed by their third-party administrator (TPA). Concerns had been raised regarding payment inaccuracies, prompting a detailed audit to uncover potential errors, overpayments, and compliance issues.

Solution

Leveraging our experienced audit professionals and proprietary AUDiT iQ™ software, BMI established key objectives to ensure claims accuracy and compliance:

  • Analyzed 100% of medical claims paid over a 12-month period.

  • Tested claims for plan compliance, eligibility, and potential fraud, waste, or abuse.

  • Audited a sample of claims based on analytical findings.

  • Delivered a comprehensive report detailing key findings and actionable cost-saving recommendations

Audit Findings

Our audit uncovered critical errors that resulted in significant overpayments and financial waste:

  • Payments for excluded dental procedures that were not covered by the plan.

  • Incorrect copayments and lack of required precertification for genetic testing.

  • Improper coordination of benefits (COB) where another insurance provider was the primary payer.

Audit Outcome

The TPA confirmed initial overpayments exceeding $28,000, and initiated efforts to identify, recover and reprocess additional related claims. Manual processing errors and incorrect system setups were identified as the root cause of the discrepancies.

At the audit’s conclusion, BMI assigned a dedicated advisor to walk through a variety of recommendations on how to hold the TPA accountable and implement preventive compliance measures to reduce future claim errors.

Medical Claims Audit, Healthcare Claims AuditRobert Temples