Faced with potential increased scrutiny of fiduciary responsibility by the Department of Labor, this client engaged BMI to conduct an audit of their self-insured medical plan to demonstrate due diligence.
Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:
- Review 100% of all claims paid during a two year period.
- Test claims against Summary Plan Descriptions, contracts and eligibility records.
- Identify and analyze areas of possible fraud, waste, and abuse.
- Confirm appropriate coordination of benefits.
- Audit a sample of claims on-site at the third-party administrator’s payment facility.
- Present detailed findings in addition to specific cost-savings recommendations based on the data and audit results.
- Provide post-audit guidance and assistance.
- Claims paid without appropriate coordination of benefits where other insurance was primary
- Payment for non-covered services
- Duplicate claims, improper coding and modifiers
Initial adjustment amounts due to incorrect adjudication totaled $30,000. A majority of the errors were attributed to auto adjudication where the processing system should have pended the claim for processor review. A dedicated Post-Audit Support Coordinator was assigned by BMI to coordinate resolution of the issues identified as a result of the audit.