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Following the Claims Dollars Leads to Confirmation of Client’s Suspicions

Audit Issue:    
Our client engaged us to conduct an audit of their medical claims administrated by their third-party administrator.  The client suspected a variety of claims processing errors including incorrect coding, copays, and duplicate claims over the course of a two-year period.

 Audit Finding:

Using a combination

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PBM Auditing Beyond Just Claims Data – A Valuable Approach.

Audit Issue:    
Our client engaged us to conduct an audit of their pharmacy benefit manager (PBM) and Rx plan benefits which included a thorough analysis and testing of relevant ASO contract language stipulations related to several financial and performance guarantees.

Audit Finding:
During the course of carefully evaluating the

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Spousal Surcharge Audit – An Effective Strategy to Reduce Costs.

Business Situation:
With the steadily increasing costs of health care, our client engaged us to conduct a Spousal Surcharge audit to ensure that spouses who are eligible for other employer-sponsored coverage are subject to an additional premium if they chose not to enroll.  The audit was also designed to

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Health Plan Audits – Immediate Recoveries & Long-Term Corrective Action

Business Situation:
Facing rising health care costs, our client engaged us to conduct an audit of medical claims paid over a two year period by their third-party-administrator. Consistent with the client’s objectives we:

  • Reviewed 100% of all claims paid during the audit period using our proprietary software AUDiT iQ
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Dependent Eligibility Audit Produces A 10:1 Return on Investment Ratio

Business Situation:
Our client was referred to BMI by their employee benefits consultant regarding their needs for a dependent eligibility audit.  The purpose of the audit was to confirm that benefit dollars were only being spent on eligible participants while meeting the following objectives:

  • Identify all dependents currently enrolled
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Periodic Dependent Eligibility Audit Achieves High ROI

Business Situation:
After a dependent eligibility audit and throughout the year there are circumstances where new dependents may be added to benefit plans. These can include life events, new hires, open enrollment, and acquisitions. After an initial dependent eligibility audit many employers, like the one highlighted below, choose an ongoing

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Multiple Audits Result in Over $500,000 in Savings and Achieves a 2,000% ROI

Business Situation:
As a cost-containment best practice, our client engaged our firm to validate its TPA’s compliance with the Administrator Services Only (ASO) agreement and Summary Plan Description (SPD) for its self-insured plans.  Our client was also seeking a firm to audit its employee’s 8,600 covered dependents to ensure

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Pharmacy Benefit Manager’s Claims Payment Errors Corrected

Audit Issue:    
With an average of a half of a million dollars spent per month on prescription drug benefits, our client engaged us to conduct an audit of their pharmacy benefit manager to include extensive examinations of plan parameters such as:

  • Excluded and/or Limited Drug Types
  • Prior Authorizations
  • Copays
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Claims Administrator Payment Errors Exceed 160k

Audit Issue:    

BMI was engaged to fulfill our client’s fiduciary responsibility to ensure its health plans were being administered in accordance with the Summary Plan Description and other compulsory directives.

Audit Finding:
Using Audit iQ to complete our forensic analysis of claims data, we selected claims for on-site review.

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Client Achieves a 1,200% Return of Investment Ratio

This time of year is ideal for any employers considering a dependent eligibility audit.  Any intentions to audit can be communicated to employees during open enrollment with an audit shortly following after enrollment closes.

Business Situation:
A large diversified worldwide specialty metals producer came to BMI regarding their needs for

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