January 9, 2012

BMI Audit Finding of the Month: Multiple Claims Paid in Error Due to Systemic Flaw

Audit Issue:
The audited health plan specifically excluded services relating to pregnancy of a dependent child except for complications of pregnancy.
Audit Finding:
Multiple claims were identified as being paid for excluded routine pregnancy services.
TPA Response:
The claims administrator agreed that claims were paid in error. In investigating the root cause of the error, they discovered a systemic flaw stemming from the plan’s allowance for complications. Apparently, the exception criteria were set up too broadly to automatically deny even routine services.
Financial Error:
The administrator agreed to recoverable financial errors of more than $79,000.