August 6, 2018

Trust, but Verify – Annual Claims Audit Finds Mistakes Continued

Business Situation 

This religious institution began conducting annual external medical claims audits with BMI after their initial audit with BMI discovered claims being paid in conflict with the plan’s intent.


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

  • Analyze 100% of all claims paid by the third-party administrator during a 12 month period directly following the previous audit.
  • Test claims against Summary Plan Descriptions, contracts and eligibility records.
  • Identify areas of possible fraud, waste, or abuse and confirm appropriate coordination of benefits.
  • Present detailed findings and specific cost-savings recommendations based on the data and audit results.
  • Provide guidance and assistance post-audit.

 Audit Findings

  • Safeguards to prevent various non-covered services from being paid following the last audit were not fully-implemented.
  • Inconsistencies with proper coding, adjudication and reimbursement.
  • Duplicate payments and copays not applied correctly.

 Audit Outcome

The third-party administrator agreed to initial over-payments exceeding $100,000 and to implement additional system edits coupled with increased examiner training.  BMI assigned a point person directly following the audit to help facilitate remaining correction actions and resolve any outstanding issues identified between the client and third-party administrator.

Coinciding with the audit, BMI analyzed plan designs against the claims data resulting in over $60,000 in 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 how a claims audit can help your organization.