PBGH - Prescription Drug Program

New!
Employer Members Only
Fees Reduced for Dependent Eligibility Audits

February, 9, 2010
PBGH is pleased to announce fee reductions to the preferred pricing for PBGH employer members for dependent eligibility audits through the program provided to PBGH by BMI Audit Services, LLC.

To assist employer members in protecting their plans from fraud and to fulfill legal and fiduciary responsibilities, BMI can identify, based on your health plan’s eligibility definition, dependents who should no longer to be covered under your employer plan. Data indicates that 3 to 12 percent of covered dependents may be ineligible for coverage, depending on employee demographics and complexity of the eligibility criteria.

Key features include:

Verification of eligibility files
Establishment of eligibility criteria
Response tracking
Benchmark reporting

BMI has conducted dependent eligibility audits for a number of PBGH employer members.

BMI also offers preferred pricing to PBGH employer members for medical claims audits. BMI has many years of audit experience with health plans in the Pittsburgh region including Aetna, HealthAmerica, Highmark, UPMC Health Plan as well as plans across the country. They have also provided these services to a number of PBGH employer members.

Combining advanced technology with time-tested audit methodologies, BMI uses a customized, innovative approach for assessing the administrative effectiveness of the medical claims audits of each individual company. BMI’s methods uncover all possible misinterpretations of plan language by administrators and employees.

Key features include:

Computer-aided systems, human logic and onsite reviews
Electronic comparison of 100 percent of enrollment records versus all paid claims
Review of all pertinent plan design documents to ensure customized auditing
Audit of all medical claims paid by the administrator within a specified time range
Reports identifying all categories of claims potentially paid in error
Benchmark reporting

BMI prepares detailed, easy-to-use reports to develop realistic, practical and cost-saving solutions.

Additional volume discounts are also available based on the total number of audits conducted across all PBGH employer members.

There are a number of PBGH employer members that have indicated they will be conducting audits during 2010. Take advantage of this preferred program through BMI and join fellow PBGH employer members to obtain further pricing improvements.

If you are interested in taking advantage of the program or have questions, contact:
Will Baker, Vice President Client Development, BMI Audit Services, LLC at wbaker@bmiaudit.com or call 800-826-7041 x123.