Subsequent Claims Audit Reveals Systemic Issues Continued

Business Situation

A large supermarket chain engaged BMI to verify whether issues uncovered in their last medical claims audit were ultimately fixed by their third-party administrator (“TPA”).

Solution

Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:

  • Analyze 100% of all medical claims paid by the TPA during an 18-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.

Audit Findings

  • Systemic payments of non-covered benefits such as contraceptives, services related to dependent pregnancies and genetic testing

  • Systemic duplicate claim payments

  • Failure to apply appropriate prior authorizations when required by the plan

Audit Outcome

The TPA agreed to initial overpayment amounts exceeding $50,000 and to run impact reports to identify additional affected claims outside of those sampled through the audit. Root cause investigation revealed manual processing errors and incorrect system setup and mapping.

At the conclusion of the audit, BMI assigned a specialist to walk through a variety of additional recommendations including both short-term and long-term solutions to resolve and prevent the opportunity for future claims processing errors from occurring.

Medical Claims Audit, Healthcare Claims AuditRobert Temples