Medical Claims Audit Yields Significant Cost Recovery
Business Situation
This city government approached BMI to conduct a retrospective audit of medical claims following concerns about proper adjudication.
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 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
Payments allowed for out of network services and excluded diagnoses that should have been denied.
Errant reprocessing resulting in overpayments.
Inconsistencies with coding and reimbursement amounts.
Audit Outcome
The third-party administrator agreed to initial overpayment amounts exceeding $135,000 while disputing an additional $265,000 in payments. BMI assigned a specialist directly following the audit to help facilitate necessary corrective actions and resolve any outstanding issues identified between the client and third-party administrator.
Visit here to learn more about auditing your third-party administrator.