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Medical Claims Audits

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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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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Medical Claims Audit Uncovers Additional Mistakes by TPA

Business Situation:

A labor union elected to conduct a medical claims audit following an unexpected increase in claims dollars compared to the previous year and the discovery of several adjudication mistakes.

Solution:

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

  • Analyze 100% of all
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Due Diligence Claims Audit Uncovers Unintended Plan Expenses

Business Situation:

This client engaged BMI to conduct a claims audit of their self-insured medical plan for due diligence purposes.

Solution:

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

  • Review 100% of all claims paid during an 18 month period.
  • Test claims against Summary
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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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