April 1, 2019

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.



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 period.
  • Test claims against Summary Plan Descriptions, contracts and eligibility records.
  • Identify areas of possible fraud, waste, or abuse and confirm appropriate coordination of benefits.
  • Audit a sample of claims based on the analysis.
  • Present detailed findings and specific cost-savings recommendations based on the data and audit results.
  • Provide guidance and assistance post-audit.


 Audit Findings

  • Plan exclusionary language not followed when medical necessity or preauthorization was required.
  • Out-of-network claims processed as in-network.
  • Inappropriate application of copayments.


 Audit Outcome

The third-party administrator agreed to initial overpayment amounts exceeding $70,000 and attributed many errors to manual claims examiner processes including overrides. BMI assigned a specialist directly following the audit to help facilitate necessary corrective actions and resolve any outstanding issues identified between the client and third-party administrator.

Coinciding with the audit, BMI analyzed plan designs against the claims data to identify hundreds of thousands in potential future savings by making suggested plan language revisions to consider going forward. Areas in the analysis contained observations where the plan is silent, lacking limitations or overly broad.

Please visit here to learn more about why errors may occur when a third-party administrator processes an employer’s health care claims.