December 1, 2017

Medical Claims Audit Uncovers Additional Mistakes by TPA

Business Situation:

A labor union elected to conduct a medical claims audit following an unexpected increase in claims dollars compared to the previous year and the discovery of several adjudication mistakes.


Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:

  • Analyze 100% of all claims paid during a 12 month period.
  • Test claims against Summary Plan Descriptions, contracts and eligibility records.
  • Identify 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 and specific cost-savings recommendations based on the data and audit results.
  • Provide guidance and assistance post-audit.

Audit Finding:

  • Incorrect out-of-pocket calculations for outpatient surgery
  • Payment for dependent pregnancy despite the plan’s exclusion
  • Providers paid for a higher level of service not supported by the diagnosis submitted

Audit Outcome:

Initial overpayment amounts due to incorrect adjudication on claims examined for the audit totaled over $25,000. The administrator admitted to many errors identified, but did not provide reasoning or outline corrective actions. Directly following the audit BMI assigned a point person to help facilitate correction and 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 $50,000 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.

Visit us here to learn more about health care claims audits of third-party administrators.