Randy Light Managing Partner

BMI Audit Finding of the Month: Dependent Eligibility Audit Finds 8.99% of Dependents Ineligible.

Business Situation: Client desired to engage an independent auditor to conduct an audit of all employees with enrolled dependents to confirm that all enrolled dependents met specific eligibility criteria defined by their plan. Client also wanted to establish an ongoing verification process for new enrollees.

Client Profile:

  • Premier

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BMI Audit Finding of the Month: TPA Overpaid More than $195K

Audit Issue: Our client’s group medical plan specifically excludes any and all surgical procedures related to the treatment of obesity “unless surgery is performed by an in-network physician using an in-network facility”.

TPA Response: The administrator confirmed our findings that bariatric surgery expenses should not have been reimbursed to out-of-network
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BMI Audit Finding of the Month: TPA Overpaid More Than $18K

Audit Issue: As standard process, claims data is scrutinized for possible duplicate payments. Comparison criteria include claims paid for same patient, same date of service, same procedure code, same charge, and same provider for different paid dates.
TPA Response: The administrator agreed that the claims processor overlooked an automated system
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