Our client, a large religious organization, requested that AIM perform a claims audit of its third party administrator, a commercial insurance carrier administering medical claims on behalf of the client’s self-funded health plan. AIM performed a statistically valid, random sample claim audit and a focused audit of large dollar claim payments.
The AIM claims audit revealed that the administrator’s performance for financial accuracy was far below both the industry standard and the administrative services agreement performance standard.
In addition, the audit identified numerous serious errors in claims processing, including:
In addition to these obvious claims processing errors, AIM discovered that the administrator was not taking any action to mitigate the financial impact to the plan of uncontrolled out-of- network facility charges, as required by the administrative services agreement.
As a result of the AIM audit, over $400,000 was recovered for the plan, and the claims administrator’s service recovery activities (instituted as a result of the audit) – including the funding of a follow-up claims audit – led to greatly improved claims processing performance for the client’s plan.
For more information contact your AIM representative at 1-866-284-4995.