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.
- 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.
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.