Our client, a large local healthcare system, requested that AIM perform a baseline claims audit of its TPA, which had been administering medical claims on behalf of the client’s self-funded employee medical plan for many years. AIM performed an operational review, a statistically valid, random sample claim audit, and a focused audit of large dollar claim payments.
The AIM claims audit revealed that the administrator was meeting both the industry standard and the administrative services agreement performance standard for financial accuracy and claims processing accuracy.
However, the audit did reveal a number of significant issues in claim processing, including:
In addition to these claims processing errors, AIM discovered a number of operations review findings, including.
As a result of AIM’s detailed review of the TPA’s claims processing performance and operational efficiency and effectiveness, a comprehensive quality improvement program was initiated specifically for the client. It addressed both the claims processing failings and the operational inefficiencies. AIM continues to work with the TPA to improve the quality of claims administration provided to the client.
For more information contact your AIM representative at 1-866-284-4995.