August 2, 2019

Medical & Rx Audit Yields Big Savings for Employer Group

Business Situation 

At the recommendation of their consultant following concerns about the accuracy of claims adjudication, this employer group approached BMI to conduct an audit of medical and prescription drug claims paid by their third-party administrator.



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

  • Analyze 100% of all medical and prescription drug claims paid by the third-party administrator during an 18 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

  • Allowance of benefit payments for excluded services such as acupuncture and cosmetic procedures.
  • Benefit payments in excess of the plan’s limitations for chiropractic care and other therapy specialties.
  • Inconsistencies with proper coding and reimbursement procedures.


 Audit Outcome

The third-party administrator agreed to initial overpayment amounts exceeding $285,000 and implement remediation efforts and recovery.  Following release of the findings, BMI assigned a specialist to help facilitate any further corrective actions and resolve any outstanding issues identified between the client and their third-party administrator.

Coinciding with the audit, BMI analyzed plan designs against the claims data to identify over $145,000 in additional potential future savings by making suggested plan language revisions to consider going forward. Areas in the analysis contained observations where the plan is silent, lacking limitations or overly broad.

Visit here to learn more about medical and prescription drug claims audits.