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Audit Finding of the Month

Claims Audits Test Third-Party Administrator Effectiveness

Business Situation 

Every few years this large group of public school districts relies on BMI to conduct a thorough review of medical claims paid by their third-party administrator to ensure the plan’s assets are being used appropriately for the sole benefit of plan participants.

 

Solution

Utilizing our experienced staff …

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Dependent Verification Equates to Real Savings

Business Situation & Client Profile:  

To ease the burden of rising health care costs and reduce risk, this manufacturer enlisted BMI’s assistance with dependent verification of  1,020 enrolled dependents on the health plan.

 

Solution:

BMI customized a dependent eligibility audit plan to meet the following goals:

  • Communicate the purpose
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Savings Follow Audit of Client’s Third-Party Administrator

Business Situation 

BMI was engaged to audit this manufacturer’s new third-party administrator for both their medical and prescription drug plans to ensure benefits were being paid appropriately and to evaluate overall administrative effectiveness.

 

Solution

Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:

  • Analyze
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Savings Follow Verification of Spousal Eligibility

Business Situation & Client Profile:  

To ease the burden of rising health care costs, this manufacturer enlisted BMI’s assistance to verify if 344 enrolled spouses were eligible under their employer’s health plan and therefore ineligible on the manufacturer’s plan. The employer also elected to verify the eligibility of 623 dependent …

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Medical Claims Audit Yields Significant Cost Recovery

Business Situation 

This city government approached BMI to conduct a retrospective audit of medical claims following concerns about proper adjudication.

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 24 month
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Small Employer Achieves Big Savings through Dependent Eligibility Audit

Business Situation & Client Profile:  

Facing rising costs to provide employee benefits, this institute of higher education contacted BMI to verify the eligibility of all 484 dependents enrolled in their health care plans.

 Solution:

BMI customized a dependent eligibility audit plan to meet the following goals:

  • Communicate the purpose of
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Claims Audits – An Immediate and Future Cost Reduction Strategy

Business Situation 

This county government client approached BMI to conduct an audit of medical and prescription drug claims for cost reduction purposes after a significant rise in insurance expenditures.

 

Solution

Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:

  • Analyze 100% of all medical
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Audit of Dependent and Spousal Surcharge Eligibility Achieve Combined Savings

Business Situation & Client Profile:  

A regional hospital and healthcare center with 650 employees covering 1,480 dependents contacted BMI to: 1) verify the eligibility of all dependents and 2) determine whether or not enrolled spouses should be paying a spousal surcharge per the plan. Verification was previously performed internally.

 

Solution:

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Trust, but Verify – Annual Claims Audit Finds Mistakes Continued

Business Situation 

This religious institution began conducting annual external medical claims audits with BMI after their initial audit with BMI discovered claims being paid in conflict with the plan’s intent.

Solution

Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:

  • Analyze 100% of all claims
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Removal of Ineligible Dependents Translates to Savings

Business Situation & Client Profile:       

A city government provides a comprehensive benefits package to 1,304 employees and their 2,663 dependents. To avoid payment of health claim claims for ineligible dependents, the city contracted with BMI to administer a comprehensive dependent eligibility audit.

 Solution:

BMI customized an audit plan to meet …

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