Our client’s internal audit staff wanted to partner with an audit firm who enabled their department to have hands-on involvement throughout the medical claims audit process. BMI’s auditors routinely allow our clients to accompany them onsite when reviewing our audit samples and in this case, allowed the employer’s internal audit staff to help select audit samples at our office to review prior to the onsite visit.
Three (3) audit samples reviewed onsite revealed that:
· Standard payment adjustment rules for multiple procedures were not applied correctly to the CPT code.
· The employee’s spouse had other insurance that would have been primary for the dependent children.
· The surgeon and assistant surgeon were each allowed the same rates when the assistant should have been paid no more than 20% of the surgeon’s allowance.
Third-Party Administrator Response:
The administrator agreed to the errors and immediately provided refunds to our client. They also agreed to perform an impact analysis to determine the total financial impact of potential similar errors.
The total amount of errors on just the three (3) audit samples above totaled over $10,000 in addition to $7,000 in unrelated errors agreed to by the administrator.