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.