February 16, 2018

Value Realized – Claims Audits Test TPA Effectiveness

Business Situation:

Every few years this municipality relies on BMI to conduct a thorough review of medical claims paid by their third-party administrator to ensure benefits are being paid appropriately.



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

  • Analyze 100% of all claims paid during a 24 month period.
  • Test claims against Summary Plan Descriptions, contracts and eligibility records.
  • Identify areas of possible fraud, waste, and abuse.
  • Confirm appropriate coordination of benefits.
  • Audit a sample of claims at the third-party administrator’s payment facility remotely.
  • Present detailed findings and specific cost-savings recommendations based on the data and audit results.
  • Provide guidance and assistance post-audit.


Audit Finding:

  • Failure to apply standard reductions for secondary procedures on ambulatory surgery center claims
  • Duplicate outpatient facility and rehab claims
  • Incorrect coding and reimbursement practices


Audit Outcome:

Initial adjustment amounts due to incorrect adjudication exceeded $120,000.  Coinciding with the audit, BMI analyzed plan designs against the claims data resulting in over $400,000 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.

The administrator agreed to provide feedback and coaching to the processing team as well as initiate a recovery process.  Directly following the audit BMI assigned a point person to help facilitate correction and resolution of the issues identified with the client and third-party administrator.

Click here to learn more about how a medical claims audit can benefit your self-funded organization.