The following are some examples of claim-related issues and other problem areas in benefits administration that were identified during audits conducted by QBA:


         Claim adjudication system detected overpayments, but clerks overrode edits – $44,508.

         System edits did not detect duplicate payments - $78,038.

         A claim not coordinated although other benefit information was submitted - $100,113.

         Thirty-four percent (34%) over funding of the call-for-funds - $114,000.

         Not performing bank reconciliations allowed stop-payments to go undetected - $234,356.

         Secondary payor paid primary without investigating the birthday rule - $330,331.

         Account funding reconciliation error - $442,103.

         Inflated claim count resulted in administrative overcharges - $617,223.

         Plan benefit change request not implemented - $797,065.

         PPO discounts not taken – estimated $2 million in loss savings annually.

         Administrative overcharge due to commingling of funds - $4.5 million.

         Payments under pay and pursue coordination not pursued – estimated loss $16 million.

         Full provider differentials were not passed back to the Plan - estimated at $5.7 million for the two-year period. This practice had been going on for many years!


These problem areas are not just claim-related – other areas, such as eligibility, administrative fees, and plan funding can also add to unnecessary plan costs. In addition to using our proprietary software to identify claim overpayments, QBA also conducts a comprehensive audit of other service areas and Plan activities to provide a complete assessment of overall Plan administration.


For Quantitative Benefits Administration (QBA) assistance or to learn more about the ideas, practices or findings, please contact us. We can assist in evaluating the control and audit processes, and identifying improvement areas in your plan.


Innovators in Auditing Health Benefits Administration

901 Waterfall Way
Suite 201

Richardson, Texas 75080

  (972) 235-3000
Fax (972)235-1990


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