August 1, 2017

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.


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 Plan Descriptions, contracts and eligibility 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.

 Audit Finding:

  • Inappropriate coding for services that should have not been allowed
  • Improper coordination of benefits when members had other primary insurance
  • Lack of investigation and recovery where potential other party liability existed

Audit Outcome:

Initial overpayment amounts due to incorrect adjudication on claims examined for the audit totaled over $25,000. The administrator agreed to aggressively pursue recovery on the overpayments and run impact reports to reveal additional financial impact. A dedicated Post-Audit Support Coordinator was assigned by BMI to coordinate resolution of the issues identified as a result of the audit.

Coinciding with the audit, BMI analyzed plan designs against the claims data resulting in over $200,000 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.

Please visit here to learn more about claims audits.