December 6, 2018

Medical Claims Audit Yields Significant Cost Recovery

Business Situation 

This city government approached BMI to conduct a retrospective audit of medical claims following concerns about proper adjudication.


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

  • Analyze 100% of all medical claims paid by the third-party administrator during a 24 month period.
  • Test claims against Summary Plan Descriptions, contracts and eligibility records.
  • Identify areas of possible fraud, waste, or abuse and confirm appropriate coordination of benefits.
  • Audit a sample of claims based on the analysis.
  • Present detailed findings and specific cost-savings recommendations based on the data and audit results.
  • Provide guidance and assistance post-audit.

  Audit Findings

  • Payments allowed for out of network services and excluded diagnoses that should have been denied.
  • Errant reprocessing resulting in overpayments.
  • Inconsistencies with coding and reimbursement amounts.

  Audit Outcome

The third-party administrator agreed to initial overpayment amounts exceeding $135,000 while disputing an additional $265,000 in payments.  BMI assigned a specialist directly following the audit to help facilitate necessary corrective actions and resolve any outstanding issues identified between the client and third-party administrator.

Visit here to learn more about auditing your third-party administrator.