This employer recently underwent an audit by the Department of Labor and wished to conduct a medical claims audit to demonstrate fiduciary oversight of their medical plan.
Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:
- Review 100% of all claims paid during a 20 month period.
- Test claims against Summary Plan Descriptions, contracts and eligibility records.
- Identify and analyze areas of possible fraud, waste, and abuse.
- Confirm appropriate coordination of benefits.
- Audit a sample of claims on-site at the third-party administrator’s payment facility.
- Present detailed findings in addition to specific cost-savings recommendations based on the data and audit results.
- Provide guidance and assistance post-audit.
- Failure to deny claims for services and procedures excluded by the plan.
- Services paid beyond the plan’s stated calendar year visit limits.
- Incorrect coding and reimbursement practices.
Initial overpayment amounts due to incorrect adjudication on claims examined for the audit totaled $40,000. The administrator immediately began to adjust the incorrect claims and run impact reports to reveal additional financial impact. Post audit, BMI assigned a point person to help facilitate resolution of the issues identified as a result of the audit.
Coinciding with the audit, BMI analyzed plan designs against the claims data resulting in over $85,000 in potential future savings by making suggested plan language revisions. Areas in the analysis contained observations where the plan is silent, lacking limitations or overly broad.
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