June 3, 2019

Comprehensive Audit of Medical Claims Uncovers Errors

Business Situation 

In support of due diligence efforts, a construction industry health and welfare fund approached BMI to conduct a comprehensive audit of 24 months of medical claims paid by their third-party administrator.



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 medical 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

  • Providers overcharged when coding existing patient visits with new patient codes.
  • Plan exclusionary language not followed for family counseling or genetic testing.
  • Coordination of benefits not applied correctly with Medicare.


Audit Outcome

The third-party administrator agreed to initial overpayment amounts exceeding $30,000, to adjust incorrect medical claims accordingly and run additional impact reports to determine the extent of issues uncovered by the audit.

Following release of the findings, BMI assigned a specialist to help facilitate any further corrective actions and resolve any outstanding issues identified between the client and their third-party administrator.

Learn more about medical claims audit solutions here.