A regional gaming and hospitality company required a detailed claims and administrative review audit of their health plans. AIM was selected to perform a statistically-valid audit of their medical and pharmacy plans.
AIM performed the on-site claims audit of their vendor and uncovered a series of adjudication and operational challenges. The audit resulted in the third-party administrator (TPA) implementing a series of system corrections to properly re-load the benefit plans. The audit also uncovered flaws in how the TPA was handling subrogation and coordination of benefits. Finally, the review revealed several instances of disconnects between the Plan Document and how the vendor was handling benefit claims.
The audit led to the negotiation of new performance guarantees between the client and their TPA, as well as an overhaul of administrative deliverables. The corrected claim payments totaled over $200,000, in favor of the client’s plan.
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