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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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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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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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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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Medical Claims Audit Starts Path to Savings & Corrective Actions

Business Situation:

As one of several cost containment initiatives, this client engaged BMI to conduct an audit of their self-insured medical plan in order to verify the accuracy of claims payments made on their behalf.

Solution:

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

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Claims and Dependent Eligibility Audit Combination Achieves Savings

Business Situation:

As part of an effort to reduce overall health care costs, this client engaged BMI to conduct an audit of their third-party administrator  to validate compliance and an audit of all enrolled dependents to verify eligibility.

Client Profile:

  • Non-Profit Organization
  • 718 Employees Covering 1,414 Dependents

 Claims Audit Finding:

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Claims Audit of Third-Party Administrator Confirms Suspicions

Business Situation:

This client engaged BMI to conduct a claims audit of their self-insured medical plan after suspecting manual and electronic processing errors, payment for excluded services and overall inconsistent adjudication practices by their third-party administrator.

Solution:

The client and BMI agreed upon the following objectives for an audit:

  • Analyze
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Claims and Dependent Eligibility Audit Combination Exceeds Expectations

Business Situation:

As part of a comprehensive risk management program, this client engaged BMI to conduct an audit of their third-party administrator to validate compliance and an audit of all enrolled dependents to verify eligibility.

Client Profile:

  • School District
  • 272 Employees Covering 693 Dependents

Claims Audit Finding:

  • Medicare claims paid
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Following the Claims Dollars Leads to Confirmation of Client’s Suspicions

Audit Issue:    
Our client engaged us to conduct an audit of their medical claims administrated by their third-party administrator.  The client suspected a variety of claims processing errors including incorrect coding, copays, and duplicate claims over the course of a two-year period.

 Audit Finding:

Using a combination

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Claims Administrator Payment Errors Exceed 160k

Audit Issue:    

BMI was engaged to fulfill our client’s fiduciary responsibility to ensure its health plans were being administered in accordance with the Summary Plan Description and other compulsory directives.

Audit Finding:
Using Audit iQ to complete our forensic analysis of claims data, we selected claims for on-site review.

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