Post-Audit Resolution Management Achieves Greater Savings
Audit Issue
BMI was engaged to audit this client’s medical and prescription drug plans to ensure benefits were being paid appropriately. The client also engaged BMI’s support to communicate the audit results and corrective actions to the administrator post-audit.
Audit Findings
Following a 100% claims data analysis and on-site visit to the claim administrator’s payment facility, medical and prescription drug coverage errors identified included:
Lack of documented medical necessity beyond an acute period of care for chiropractic claims.
Payment for excluded services such as speech therapy.
Incorrect copayment applications for mail order drugs.
Payment for excluded blood products.
Third-Party Administrator/Carrier ResponsE
Immediately following the on-site visit and data analysis, the claims administrator agreed to claim payment errors on a majority of potential errors identified totaling over $100,000. The claims administrator disagreed with payments on claims involving an excluded blood medication citing that it was on the Specialty Care Drug list.
Audit Benefits/Outcome
Following the issuance of final reports, BMI engaged the administrator on behalf of the client through series of meetings to review the audit findings in greater detail with particular focus on the blood medication specifically excluded by plan language.
All parties came to an agreement and the claims administrator credited the client for more than $675,000 in errors as a direct result of BMI’s post-audit assistance.