How the BIA Audit is Scored
Table of Contents
Overview
A BIA audit is scored based on what are known as "in sample" opportunity points and "out of sample" opportunity points, as well as the number of in and out of sample errors.
Opportunity Points
In Sample Opportunity Points
There is one in sample opportunity point available per in sample test scenario, per benefit level, per benefit option. In sample modifications of CPT and diagnosis codes do not impact the number of in sample opportunity points.
For example, consider a BIA audit with 10 in sample test scenarios, each of which have benefit levels of "in network" and "out of network" and six benefit options. The number of in sample opportunity points is then calculated as
10 * 2 * 6 = 120Out of Sample Opportunity Points
Similarly, there is one out of sample opportunity point for each out of sample test scenario per benefit level, per benefit option.
Additionally, there is one out of sample opportunity point for each in sample test scenario/benefit level/benefit option combination that has an out of sample CPT or diagnosis code modification. Having more than one out of sample CPT/diagnosis code modification on a test scenario/benefit level/benefit option combination does not increase the number of out of sample opportunity points.
Errors
Each test scenario on an audit can have any number of ICEs. Any ICE of item type "Error" marked as "In Sample" is considered an in sample error. Conversely, any ICE of item type error marked "Out of Sample" is considered an out of sample error. If a test scenario has no out of sample CPT or diagnosis code modifications it can only have in sample errors.
Scoring
In Sample Scoring
If one or more finalized in sample errors exist on a test scenario/benefit level/benefit option combination, the in sample opportunity point for that combination is not recieved. Otherwise, the opportunity point is recieved. Note: it is possible to have an out of sample error on an in sample test scenario, however this does not impact the audit's in sample score.
Out of Sample Scoring
If one or more finalized out of sample errors exist on a test scenario/benefit level/benefit option combination, the out of sample opportunity point for that combination is not recieved. Otherwise, the opportunity point is recieved. Note: it is not possible to have an in sample error on an out of sample test scenario.
Full Example
Note: "Provision" is synonymous with test scenario. "Plan" is synonymous with benefit option.