Our client engaged us to conduct an audit of their medical claims administrated by their third-party administrator. The client suspected a variety of claims processing errors including incorrect coding, copays, and duplicate claims over the course of a two-year period.
Using a combination of our proprietary software AUDiT iQ™ to review of 100% of all claims paid during the audit period and an on-site visit to the administrator, BMI confirmed the following types of errors:
- Laparoscopic procedures billed without required primary procedures
- In-network co-pays processed as out-of-network co-pays
- Duplicate payments for same facility services
- Unbundling (billing components of a service/procedure separately when they should one)
Directly following the on-site visit, the third-party administrator agreed to the errors without question. The administrator also agreed to address inadequacies in their claims processing software and internal adjudication policies.
This audit finding identified over $50,000 in claims processing adjudication errors leading to additional ad-hoc reporting to quantify the overall financial impact of the errors. A credit for the amount of these errors was requested and applied. A subsequent audit is being planned to ensure compliance with corrective actions.