Pre-Implementation Audit Prevents Costly Mistakes

Business Situation

A client within the healthcare sector approached BMI to conduct a pre-implementation audit after deciding to consolidate two different existing plans with a single third-party administrator (“TPA”). The employer wanted assurance that the TPA’s system was set up appropriately according to each plan’s benefits. 

Solution

After reviewing plan documentation, auditors selected and customized over 600 test claims across the client’s 2 health plans covering a variety of claims scenarios including limitations, authorizations, exclusions, deductibles and out-of-pocket maximums.  Accuracy testing was conducted via WebEx over the course of a week with the TPA.

Audit Findings

Over 40 inconsistencies between plan documentation and system setup were discovered which included items such as:

  • Age and copayment requirements for colonoscopies incorrectly applied

  • Out-of-network deductibles and copayments not applied to out-of-pocket maximums

  • Several benefit frequency and dollar amount maximums incorrectly programmed

  • Various in network Tier 1 and Tier 2 services not adjudicated according to existing plan intent

  • Certain benefit parameters not captured correctly or mentioned in existing plan documentation

Audit Outcome

Through this independent testing,  this client was able to catch and prevent costly mistakes and avoid future claims adjudication headaches.  Many findings identified areas where the client needed to clarify the intended benefit and instruct the TPA to make subsequent plan language revisions.

Implementation AuditRobert Temples