Implementation Audit Uncovers Hidden Discrepancies
Business Situation
A client within the financial services industry approached BMI to conduct an implementation audit after moving to a new carrier. Their primary objective was to verify whether the carrier’s system was set up appropriately to administrate their claims according to plan benefits.
Solution
After reviewing plan documentation, auditors selected and customized 375 test claims across the client’s 6 health plans covering a variety of claims scenarios including limitations, exclusions, deductibles and out-of-pocket maximums. Accuracy testing was conducted via WebEx over the course of a week with the carrier.
Audit Findings
Over 20 inconsistencies between plan documentation and system setup were discovered which included items such as:
Visit limitation discrepancies for chiropractic, home health care and inpatient rehab services
Out-of-network dialysis paid at 100% vs. 60% after deductible
Multiple copayment, coinsurance and deductible discrepancies for in and out-of-network benefits
Audit Outcome
Through this independent testing, this client was able to catch potential costly mistakes and avoid future claims adjudication headaches. The carrier ran impact reports and corrected some findings identified during the audit while others need further verification by the client on the intended benefit and subsequent plan language revisions.
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