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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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Pharmaceutical Audits Yield Significant Cost Recovery

Business Situation 

This public school district engaged BMI to conduct a pharmaceutical claims audit of their self-insured pharmaceutical plans and pharmacy benefit manager (PBM).  In addition, the client also engaged BMI to conduct an on-site rebate audit, as well as a complete contractual financial guarantee audit.

Solution

BMI performed three …

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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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Prescription Drug Payment Errors Prove Costly Following Audit

Audit Issue:    

Client plan language indicated 1) an age edit rule for acne medication, 2) an exclusion for fertility drugs and 3) a prior-authorization requirement on several drugs.   
 

Audit Finding:

Using our proprietary software AUDiT iQ™, we identified paid claims for acne medication where the members had

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PBM’s System Not Correctly Programmed: Approvals Given Despite No Prior Authorization

Audit Issue:    

We reviewed prescription drug plan claims data provided for any potential systemic error issues regarding exclusions, drugs requiring prior authorizations, limitations, etc.

 
Audit Finding:

Though the plan excluded drugs or supplies used for the treatment of erectile dysfunction, impotence or sexual dysfunction or inadequacy, multiple drugs used …

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BMI Audit Finding of the Month: Audit Finds Prior Authorization Not Provided Prior to Claims Payment

Audit Issue:
The audited health plan required prior authorization for Durable Medical Equipment (DME) charges exceeding a stated amount.

Audit Finding:
We used AUDiT iQ to select sample DME claims for on-site review.  While on-site at the Administrator’s payment location, we confirmed that prior authorization was not provided prior to …

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