April 8, 2013

Health Plan Audit Reveals Payment of Excluded Services and Lack of Documented Medical Necessity

Audit Issue:    
BMI was engaged to audit our client’s health plans to ensure benefits were being paid appropriately after several benefit plan changes were made going into the new plan year.

Audit Finding:

Six (6) audit samples reviewed onsite with over 150 related claim lines revealed that:

  •       No documented medical necessity for chiropractic treatment beyond an acute period of  care was on file.
  •      Genetic testing services did not meet the plan’s criteria for coverage.
  •     Family counseling services were paid for despite being excluded from the plan.

Third-Party Administrator / Carrier Response:
The claims administrator agreed to the errors and committed to conduct additional processor training and monitor error categories identified in the audit to avoid payments on excluded services.

Financial Error:

Total payment errors found as a result of the audit amounted to over $24,000 for the audit samples reviewed on-site.