August 5, 2015

Pre-Implementation Audits – An ounce of prevention is worth a pound of cure.

Business Situation:  

After dropping some plan options and adjusting others from the prior plan year, this employer engaged BMI to conduct a pre-implementation audit with their claims administrator.   
 Audit Finding: 

BMI tested areas with claims scenarios that included, but were not limited to deductibles, co-pay levels, coinsurance, exclusions and limitations. Some issues identified included:
  • Various wellness services were set to pay regardless of age or frequency.
  • Plan limits for rehab and chiropractic visits not set properly to deny.
  • Emergency room charges set to pay at in-network rates regardless of provider.
  • Plan language conflicts regarding abortion and transplant benefits.
Claims Administrator Response:
The claims administrator adjusted their system set-up based on BMI’s findings and clarified plan intent with the client.
Audit Outcome:
While it is true that claims administrators do their own plan testing before implementation, it is only as good as what they program. This client, through independent testing, was able to catch potential costly mistakes and avoid future claims adjudication headaches by verifying the claim administrator’s system set-up before actual claims were paid.