Our client’s employee benefits consultant engaged us to conduct an audit of their client’s third-party administrator to ensure medical and prescription drug claims were being paid appropriately.
Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:
Review 100% of all claims paid during a two year period.
Test claims against Summary Plan Descriptions, contracts and enrollment records.
Identify and analyze areas of possible fraud, waste, and abuse.
Confirm appropriate coordination of benefits.
Audit a sample of claims on-site at the third-party administrator’s payment facility.
Present detailed findings in addition to specific cost-savings recommendations based on the data and audit results.
Provide post-audit guidance and assistance.
- Incorrect application of copays and deductibles.
- Duplicate claims and improper coding.
- Failure to establish medical necessity for durable medical equipment.
BMI’s analysis of plan designs and claims data also identified over $380,000 in potential future savings by making suggested plan language revisions. Areas in the analysis contained observations where the plan is silent, lacking limitations or overly broad.