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.
- 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
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.
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