June 1, 2016

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

Business Situation:
After making changes to benefit plan design from the prior plan year, this employer engaged BMI to conduct a pre-implementation audit to verify that the claim administrator’s system was programmed correctly.
After reviewing plan documentation, auditors reviewed and set up over 85 test scenarios focusing on overall plan provisions such as deductibles, coinsurance maximums, plan limits or exclusions. Multiple claims were often used to test various benefits which included claims covering different procedures, diagnoses, types of providers, age and gender. Testing was performed in a WebEx environment.
Audit Finding:
  • Out-of-network provider set to pay at in-network coinsurance levels.
  • Travel immunizations weren’t denied despite being excluded.
  • Routine colonoscopies and mammograms paid at 100% without deductible regardless of age.
  • Incorrect application of copay when a member saw more than one physician in the same clinic on the same day.
Audit Outcome:
Through independent testing this client 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.