Benefits Claims Intelligence provides a full suite of services designed to protect plan assets, ensure regulatory compliance, and recover funds lost to fraud, waste, abuse, and errors. Our AI-powered platform and experienced team deliver insights that traditional auditors simply cannot match.
Claims Auditing
Our core service — comprehensive analysis of 100% of your healthcare claims data. Unlike traditional sample-based audits, we examine every single transaction to identify:
- Billing errors and duplicate payments
- Invalid procedure codes and upcoding
- Out-of-network payment irregularities
- Provider billing pattern anomalies
- Coordination of benefits issues
- Contractual rate discrepancies
Our initial audit typically analyzes 2-4 years of historical claims data, with reports delivered within approximately 90 days.
Ongoing Monitoring
After the initial audit, our monitoring service catches issues in real-time rather than retrospectively. Benefits include:
- Prevention of future overpayments
- Continuous compliance verification
- Early detection of emerging fraud patterns
- Predictable operational stability
- Lower cost than periodic audits
- Real-time alerts on anomalies
Ongoing monitoring provides plan sponsors with continuous peace of mind and proactive protection.
Recovery Services
BCI doesn't just identify problems — we provide the documentation and support needed to actually recover funds. Our recovery support includes:
- Legally defensible audit documentation
- Detailed claim-level findings with evidence
- Recovery demand letter support
- TPA and provider negotiation guidance
- Documentation for legal proceedings
- Fiduciary reporting packages
Clients typically recover 2-8% of annual claims spend through our comprehensive audit and recovery process.
Compliance Support
Navigate complex regulatory requirements with confidence. We help plan sponsors meet their fiduciary obligations under:
- ERISA: Fiduciary duty to act prudently in managing plan assets
- PHSA: Public Health Service Act health plan requirements
- CAA: Consolidated Appropriations Act transparency and gag clause prohibitions
- HIPAA: Privacy and security compliance for health information
- ACA: Affordable Care Act coverage requirements
Our compliance documentation helps demonstrate prudent fiduciary oversight to regulators and auditors.
ERISA & PHSA Compliance
Plan fiduciaries face increasing scrutiny from federal courts, the Department of Labor, and the IRS. The Employee Retirement Income Security Act (ERISA) and the Public Health Service Act (PHSA) create specific obligations for those managing self-insured health plans:
ERISA Fiduciary Duties
- Duty of Prudence: Manage the plan with care, skill, prudence, and diligence
- Duty of Loyalty: Act solely in the interest of plan participants and beneficiaries
- Duty to Follow Plan Documents: Administer the plan according to its terms
- Duty to Monitor: Regularly review plan operations and service providers
PHSA Requirements
The Public Health Service Act (Title XXVII) establishes requirements for group health plans, including:
- Mental Health Parity: Ensuring financial requirements and treatment limitations for mental health/substance use benefits are no more restrictive than medical/surgical benefits
- Preventive Services: Coverage requirements for preventive care
- Dependent Coverage: Extended coverage for adult children
- Pre-existing Condition Protections: Prohibition on coverage denials
- Claims and Appeals: Required procedures for claims processing and appeals
Consolidated Appropriations Act (CAA) 2021
The CAA created new requirements for health plan transparency that affect fiduciary obligations:
- Gag Clause Prohibition: Plans cannot have contract provisions restricting access to claims data or provider pricing information
- Annual Attestation: Plan sponsors must annually attest to compliance with gag clause prohibitions
- Price Transparency: Enhanced requirements for cost and quality information disclosure
BCI helps identify prohibited contract provisions and provides documentation supporting compliance with these requirements.
Who We Serve
Our services scale from mid-sized employer plans to state-level government programs:
- Self-Insured Employers: Companies with 1,000 to 15,000+ employees seeking comprehensive plan oversight
- Municipal & Government Plans: City, county, and state employee health plans requiring fiduciary compliance
- Insurance Trusts & Pools: Multi-employer trusts and insurance pools seeking cost containment
- State Medicaid Programs: Large-scale oversight of managed care organization compliance and billing accuracy