Recurring Claims Audits Prove to be Beneficial
Business Situation
Every few years this industrial sector employer relies on BMI to conduct a thorough review of medical claims paid by their third-party administrator to ensure benefits are being paid appropriately.
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 28 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
Payment for claims on members who were ineligible at the time of service provided.
Failure to adhere to plan exclusionary language for various treatments and supplies.
Claims paid after the deadline to submit.
Audit Outcome
The third-party administrator agreed to initial overpayment amounts exceeding $50,000 while disputing others. BMI assigned a specialist to help facilitate any further corrective actions and resolve any outstanding issues identified between the client and their third-party administrator.