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Audit of Medical Claims
Processed by
United Healthcare, Inc.
MARTIN MATSON City Comptroller
AYCHA SIRVANCI, CPA Audit Manager
City of Milwaukee, Wisconsin
March 2014
C
C
U
AaF
J
F
S
S LAS1T66
Copyright © 2013
City o
UNITE
Analysand PaFor the P
January
Final Re
Septemb
Submitted
Lynda A. ShAdministratSegal Cons1230 West Tempe, Ariz602-381-40602-532-76
3 by The Segal G
f Milw
ED HE
sis of CaymenPeriod
1 throug
eport Re
ber 16, 2
By
heldon, HIAion and Tec
sulting Washingtozona 85281
046 654
Group, Inc. All rig
waukee
EALT
Claimsnt Proc
gh Decem
eleased
2013
A chnology C
n Street, S1-1248
ghts reserved.
e
THCAR
s Procecedure
mber 31,
Consulting
uite 501
RE
essinges
, 2012
Mitc Rut Seg 101 Chic 312
g
ch Bramsta a
h Donahuegal Consulti North Waccago, IL 60
2-984-8500
aedt, Vice Pand e, Vice Presing cker Drive, 0606-1724
President
sident
Suite 500
Benefits, Compensation and HR Consulting. Member of The Segal Group. Offices throughout the United States and Canada
CONFIDENTIALITY STATEMENT
Release of electronic and hardcopy information for this analysis required execution of an
agreement signed by the City of Milwaukee, The Segal Company, and United Healthcare on
behalf of itself and its subsidiaries.
All audit information and findings prepared and presented in this report are considered
confidential and proprietary. Sharing of contents with any other party or the copying of
information herein is expressly prohibited without the written consent of the agreeing parties.
Ta b
City of Final ReSeptemb
S
S
S
l e o f
Milwaukeeport Releasber 16, 2013
ection I – Exe
Scope of S
Statistical
Targeted S
Recomme
ection II – Cla
Individual
Premium P
Selection o
Turnaroun
Claim Con
ection III – U
f C o n
ee sed
ecutive Summ
Services ........
Achievement
Sample .........
ndations .......
aims Audit Re
Claims Revie
Physicians ....
of Claims ......
d Time Analy
ntrol Measures
HC’s Report R
n t e n t
mary ..............
.....................
t ....................
.....................
.....................
eview ............
ew ..................
.....................
.....................
ysis ................
s ...................
Response .....
t s
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................. 1
................. 1
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................. 2
................. 3
................. 4
................. 4
................. 4
................. 5
................. 5
................. 5
................. 9
i
Sect
This repoUnited Hbenefits. during th
Scope
A data Decembeprovidedcompone
An A
A strstatis
A tardupli
The audidocumenclaims adWorkshe
Statist
Of the 75assessed.coinsurancalculatio
Financia
Claims
Paymen
Process
*100% ele
ion I –
ort analyzesHealthcare (U
Lynda Shehe week of Ju
of Servic
file of all er 31, 2012,
d by UHC ents:
Adjudication
ratified samtical validity
rgeted samplicate paymen
itor completntation on whddressed witeet number in
tical Achi
5 stratified c. An Other nce was excon of statisti
C
al Accuracy
Processing A
nt Accuracy
ing Timeline
ctronic calcula
– Execu
s and evaluaUHC) in theeldon conduculy 8, 2013.
ces
medical cl, representinfor our sam
Review to a
mple of 75 cy with comp
le of claims nts.
ted a form fhich our repothin this repndicates the
ievement
claims auditClaim Matt
ceeded; this ical achievem
Category
(dollar value)
Accuracy (ov
(incidence)
ess (within 10
ation based on
utive S
ates the claieir administrcted the ons
laims proceng $90,988,9mpling purp
assess claim
claims totaliarison to ind
to provide r
for each claiort is based.
port are refersample is a
t
ed, 74 were ter is noted is noted for
ments.
Performan
verall incidence
business days
14 calendar da
Summa
ms processiration of thesite review a
ssed during987.02 in beoses. Our
control mea
ing $1,135,2dustry standa
representatio
im sample s Due to the rred to as “Wtarget sampl
processed won an out-or informatio
nce Measur
StAch
10
e) 9
10
)* 9
ay measuremen
ary
ing and paye City of Miat UHC’s Ol
g the audit enefit payme
claims rev
asures;
230.55 in bards; and
on of selecte
elected; thisconfidential
Worksheets.”le selection.
without erroof-sample clonal purpose
rement
atistical hievement
00.00%
99.86%
00.00%
98.72%
nt.
yment procedilwaukee’s gldsmar, Flor
period Janents on 239
view include
benefit paym
ed benefit ty
s worksheet lity of name” The letter
or. One procaim where t
es and is no
IS
9
9
9
9
dures utilizegroup healthrida claims o
nuary 1 thr,086 claimsed the follo
ments to pro
ypes and pote
was the pries, diagnosisr T precedin
cedural errorthe calendar
ot included i
ndustry tandard
99.00%
95.00%
97.00%
90.00%
1
ed by h plan office
rough , was
owing
ovide
ential
imary , etc.,
ng the
r was r year in the
Based oncategory Turnarou
A basic pof all clastratum. comparissample p
Industry by majoperformaemployer
Target
Fifteen tapotential following
P
T
H
A
D
Rw
B
Our elecselected services, paid base
The remaelectroniOnsite reduplicateadjustmethe system
Segal recpaymentsfinancial
n the statisduring the
und time is p
principle of aims; therefo
The total son to indusproduces a 90
standards arr carriers a
ance for admr plan benefi
ted Samp
argeted claimdiscrepanci
g areas:
hysical Ther
Temporoman
Hearing aids
Acupunture, a
Dental care o
Routine foot with a severe
Biofeedback
ctronic analyfrom specifdiabetic ma
ed on Plan b
aining eight c analysis oeview of cl
es were exents). Basedm edit durin
commends Us during theimpact to th
tical findinge benefit yepresented in E
the samplingore, the respe
projected estry standard0% confiden
re developedand third paministration fits.
le
ms were inclies based o
rapy service
ndibular Join
for ages 19 a
acupressure,
ther than tho
care (cuttinsystemic di
services
yses did nofic claim typanagement ienefits.
claims seleof 100% of laims documxplained (i.ed on our findng processing
UHC generate audit periohe Plan. Seg
gs, UHC’s ear. Error Exhibit B; th
g technique ective strataerrors are uds. With ance level wit
d through onarty adminisof fully-ins
luded as partn calendar
s exceeding
nt treatment e
and older
, massage th
ose identified
g or removasease or indi
ot identify apes not reprtems, ostom
cted for revf claims. Fmentation ane., differen
dings, all errog.
te a system od. Resultsgal also reco
achievemendetails are
he stratificat
is that the sterror rate is
sed to calcun observed h ±5% preci
ngoing reviestrators natisured and se
t of the revieyear benefi
50 visits
exceeding $
herapy servic
d under Den
al of corns, ividuals with
any potentiaresented in
my supplies);
iew were idour duplicand UHC re
nt providersors resulted f
analysis to is should be ommends UH
nt exceeded included in
tion table is E
tratified auds used to proulate the sterror rate o
ision.
ew and comionwide. Self-insured c
ew. The datit maximum
1,250 in pay
ce payments
ntal Services
nail trimminh diabetes
al errors; ththe stratifie
; our review
dentified as pates were coeview reveas under onfrom human
identify and provided tHC provide
industry stn Section IExhibit C.
dit findings aoject the totatatistical accof 3% or le
mparison of mStandards incorporate, pu
ta file was qums or plan e
yments
s
ng, debridin
herefore, seved selection w determined
potential duponfirmed totaled the remne group nn interventio
validate addto the City examiner re
tandards in II as Exhib
are represental errors forcuracy leveless, the 75 c
measures utinclude accepublic, and m
ueried to ideexclusions in
ng) not assoc
ven claims (i.e., ambu
d all claims
plicates fromtaling $6,15
maining potename, modin and overri
ditional dupto determinetraining to s
2
each bit A.
tative r each ls for claim
ilized ptable multi-
entify n the
ciated
were ulance
were
m our 59.63. ential ifiers, ide of
licate ne the stress
the impoduplicate
Recom
All questwith UHidentifiedtheir Auincluded
UHCpaymfinan
UHCrepeaevent
Segaladjud
UHCinvesSAMPL
Feed
The uprovishoul
Eachreducwill rreque
UHCchang
UHCMilw
This repextended
ortance of ae edit to a cla
mmendatio
tions and coHC personned in this rep
ugust 13th reas Section I
C should gements during ncial impact t
C’s standardatable (e.g., ts.
l notes that dication.
C should prostigation whLE, PAGE 2 AND
dback and ref
underpaymeider with anld be issued
sample errce similar ocreport back ested overpa
C should advges in adjudi
C will be hawaukee that a
ort would bd by UHC sta
accurate claiaim.
ons
omments regel. The folort. UHC wesponses haIII.
enerate a sythe audit p
to the Plan.
d process issystem prog
all errors a
vide examinhen the systD EXHIBIT A, E
fresher train
nt should ben explanationbased on the
ror has beenccurrences h
to the City ayments.
vise the Cityication proce
appy to disare a direct r
be incompleaff during th
im history i
garding the sllowing recowas presenteave been pa
ystem analyeriod. Resu(TARGETED SA
s to run impgramming).
associated w
ner retraininem attaches
ERROR LISTING
ning has been
e reopened an. Refund e City’s dire
n reviewed ahas been disc
of Milwauk
y of Milwauedures result
scuss modifiresult of this
te without rhe preparatio
investigation
statistical anommendationed with a draaraphrased i
ysis to idenults should bAMPLE, PAGE 2
mpact report Manual ad
with duplica
g to stress ts a potentia
G, PAGE 6)
n reviewed w
and additionrecovery foction. (EXHI
and the root cussed withikee quarterl
ukee of any ting from thi
fications to review.
*****
recognition on and onsite
n when the
nd targeted cns are offeraft report foin italics.
ntify and vbe provided 2 AND EXHIBIT
ts on the erdjudication e
ate payments
the importanal duplicate
with the resp
al paymentsor the identiIBIT A, PAGE 6)
cause alongin UHC. Thly with the a
modificationis review.
system prog
of the coope phase of th
system atta
claim samplered for add
or their revieTheir comp
validate addto the City
T A, ERROR LIS
rrors that aerrors are h
s were the
nce of accuredit to a c
ponsible pro
s sent to the fied duplica)
g with remee Account Mamounts rec
n to system
gramming w
peration andhis project.
aches a pote
es were revidressing conew and commplete respon
ditional dupto determin
TING, PAGE 6)
are identifiehandled as s
result of m
rate claim hiclaim. (TARG
cessors.
employee aate overpaym
ediation effoManagement covered from
programmin
with the Ci
d profession
3
ential
iewed ncerns ment;
nse is
licate ne the
ed as single
anual
istory GETED
and/or ments
rts to team
m the
ng or
ity of
alism
Sect
UHC proDecembeprocessinonsite dis
Individ
Prior hisaddition
Claim
Docuclaim
Claimthe cl
Amoufor ththe cobut dappro
Beneas an
Appr
Coor
Arith
Dupl
Premiu
UHC’s pprovide qminimize
The dataclaim. Wnot offer reflected
ion II –
ovided a daer 31, 2012 ng informatiscussions, au
dual Claim
tory and bento verifying
ms were paid
umentation (ms paid and v
ms were paidlaims system
unts paid wehe area wherondition treadid ascertaiopriate.
fits were pa incorrect en
ropriate bene
dination of b
hmetic calcul
icate claims
um Physic
premium proquality care e their cost-s
a was queriedWe eliminate
the premiumapproxima
– Claim
ata file of alto use in ouon was verifuditor observ
ms Review
nefit maximthe amount
d in strict acc
(provider bilverified when
d only on behm.
ere within thre treatmentated, based oin that the
aid under thentry may affe
efit limitation
benefits prov
lations were
were proper
cians
ogram is avaefficiently.
share and the
d and categoed those claim provider pately 48% o
ms Aud
ll medical cur electronicfied throughvations, and
w
mums were repaid, audit s
cordance wit
lls, physician necessary.
half of eligib
he designatet was renderon schedule
claims per
e proper benect payment
ns, deductib
visions were
correct.
rly denied.
ailable to Cit Members a
e plans’ resp
orized basedims where sprogram. Ouof the plan
dit Rev
claims procec analyses a
h UHC’s respthe individu
eviewed, as samples wer
th Plan prov
an statement.
ble individua
ed non-contrred, with dues utilized. Wrsonnel pro
nefit classifiaccuracy or
les, and coin
e enforced, w
ty members are encouragponsibility.
d on the Premervices wereur analysis o
n payments
view
essed and pand audit prponses to ouual claims re
applicable, re thoroughly
visions.
ts, surgical r
als, based on
racted allowe consideratWe did not d
operly review
ication, diagr future bene
nsurance wer
where applica
as a resourcged to utiliz
mium Provie rendered inof the remain
(approxima
paid from Jareparations. ur adjudicatieview.
on each stry reviewed t
reports, etc.)
n eligibility
ances and/otion given fodetermine mwed or ref
gnostic, and efit determin
re applied.
able.
ce in selectine premium p
ider Indicaton a market wning programately 51%
anuary 1 thrRelevant c
on questionn
ratified claimto determine
) was on fil
data contain
r discountedor the severi
medical neceferred claim
procedure cnations.
ng providersproviders to
or assigned twhere UHC m-eligible cof claims)
4
rough laims naire,
m. In e that:
le for
ned in
d fees ity of
essity, ms as
codes,
s who o help
to the does laims were
submittedby all eli
Select
The selerepresentformulaequantifiaof the act
Turnar
UHC bastandardsdays. Bebusiness
Segal perreceived revealed days; the
Our revieto determwithin or90 days. were due
Claim C
Our audicontrol m
review
claim
autom
estab
autom
estab
d for servicegible membe
ion of Cla
ection of cltation in the designed able degree otual way all
round Tim
ases timelines indicate 90est practice,or 30 calend
rformed an eand procesUHC excee
e results were
ew identifiedmine any addr outside the Three claim
e to provider
Control M
it samples rmeasures in t
w of claims
ms received e
mated duplic
lished proce
mated calcul
lished intern
es provided bers (e.g., act
aims
laims was se sample. to take ful
of confidencclaims were
me Analys
ess on busin0% of all cla which follodar days.
electronic tussed dates peded industrye 99.84% in
d 378 claimsditional receaudit period
ms within thrs submitting
Measures
review and the processin
data for ade
electronically
cate checking
edures for the
ation of fee
nal audit pro
by premiumtives, early re
stratified byThe metho
ll advantagee so the resu
e processed d
sis
ness days, waims should ows Departm
urnaround timprovided ony standards 30 calendar
s processed eived or prod. This is tyhe statisticalg late charge
onsite discung and paym
equacy of inf
y (88.57%);
g edits
e denial and
allowance b
cedures for q
m providers. etirees, and
y dollar amodology of e of statistiults obtainedduring the au
which exclube processed
ment of Lab
me analysis the claim
with 98.72%r days.
between 31 ocessed dateypically evidel sample fells or correcte
ussions revement of claim
formation ne
auto-adjudic
d appeal proc
based on date
quality contr
Our analysiMedicare el
mount to givour stratifieical samplind in the audiudit period.
udes holidayd within 10
bor regulatio
for 100% ofdata file.
% of all clai
and 229 days for claim enced in thel within the ed bills.
ealed UHC ms:
eeded to proc
cation (85.36
cess
e of service
rol
is is based onligible retiree
ve large claed selection ng procedurit sample are
ys and weebusiness dayns, requires
f all paid claThe results
ims processe
ys; howeverintervals du
e number of 31 to 229 d
utilizes the
cess the clai
6%)
n claims inces).
aims more process ut
res that alloe a true refle
kends. Indys or 14 cale100% with
aims based os of our anaed in 14 cale
r, we were unue to adjustmclaims excee
days; adjustm
following c
m
5
curred
valid tilizes ow a ection
dustry endar
hin 20
on the alysis endar
nable ments eding ments
claim
Works
46F
64F
T1
T4
T5
T8
Tot
Segal recand/or prshould be
heet Pa
F Pr
F OthM
$
$
$1
$2
tal $6,
commends throvider withe issued base
Over ayments
ocedural
her Claim Matter
$813.34
$836.73
1,737.55
2,772.01
159.63
he underpay an explanated on the Cit
STRAT
Request foerror durinof serviceevent resu
$68.40 fimaximum
TARG
Duplicate
4 1 1
OverpProcedOther
yment be reotion. Refundty’s directio
TIFIED SAMP
or a Medicarng manual a prior to her
ulted in a “no
le underpam was exceed
ETED SAMPL
payments m
payments dural Claim Matt
opened and ad recovery fn.
Explanat
PLE
re explanatioadjudication r 65th birthdo pay” claim
ayment. Cded on a man
LE
made during
ter ($68.40 u
additional pfor the identi
tion
on of benefito an indivi
day; the origm.
Calendar yenually adjud
manual adju
underpaymen
ayment sentified duplica
Exhibit A –
its was madeidual for a d
ginal process
ar coinsuradicated claim
udication.
nt)
t to the empate overpaym
6
– Error Listing
e in date sing
ance m.
loyee ments
g
C
Calendar Days
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31-89
91-229
Total
oNumber
of Claims
48,024
106,024
10,622
16,096
15,989
7,416
14,809
7,323
3,006
2,003
1,526
796
831
828
723
626
417
266
277
198
92
124
107
98
87
88
69
59
71
66
47
352
26
239,086
InP
2
4
10
Exhibit B – E
ndividual Percent
20.09%
44.35%
4.44%
6.73%
6.69%
3.10%
6.19%
3.06%
1.26%
0.84%
0.64%
0.33%
0.35%
0.35%
0.30%
0.26%
0.17%
0.11%
0.12%
0.08%
0.04%
0.05%
0.04%
0.04%
0.04%
0.04%
0.03%
0.02%
0.03%
0.03%
0.02%
0.15%
0.01%
00.00%
Electronic Cla
CuP
1
*may not
aims Processi
umulativePercent*
20.09%
64.43%
68.87%
75.61%
82.29%
85.40%
91.59%
94.65%
95.91%
96.75%
97.39%
97.72%
98.07%
98.41%
98.72%
98.98%
99.15%
99.26%
99.38%
99.46%
99.50%
99.55%
99.60%
99.64%
99.67%
99.71%
99.74%
99.76%
99.79%
99.82%
99.84%
99.99%
100.00%
add due to rou
7
ing Timelines
unding
s
Strata
A
B
C
D
E
F
G
Claimrespeinclu
Stratconfireflec
Zerorepre(i.e.,
Dolof
$0.0
$70.00
$280.00
$950.00
$3,000.00
$9,500.00
$42,500.0
Tota
m Definitionect to a submding all adju
tification Prdence (90%ction of the w
Payments:senting 23.7duplicates, i
lar Range f Strata
1 - $6
0 - $27
0 - $94
0 - $2,99
0 - $9,49
0 - $42,49
0 - $241,07
als
n: The definmission (anyustments mad
rocess: Ou with ±5% pway all claim
: The data 71% of all insufficient i
Numin ASele
9.99 13
9.99 12
9.99 10
9.99 10
9.99 10
9.99 10
8.41 10
75
nition for auy form, bill, de after the i
ur stratified precision) soms were proc
file containclaims. Th
information,
mber Audit ction
Nuof Cin R
3 9
2 9
0 3
0 1
0
0
0
5 23
udit purposesor other docinitial transa
sampling pro the samplecessed durin
ned 74,301 his percenta exceeding b
umber Claims Range
Do
99,239
93,634
31,188
10,600
3,422
894
109
39,086 $
s is the actiocumentationaction.
rocedure pre dollar valueng the audit p
zero paymeage is withibenefit maxi
Exh
ollar Amounin Audit Selection
$348.00
$1,874.02
$5,529.8
$16,178.09
$45,727.5
$155,140.8
$910,432.20
1,135,230.5
on taken by an submitted i
rovides a que and incideperiod.
ent claims fin reasonablimums, etc.)
hibit C – Strat
nt Total DAmou
Stra
0 $2,915
2 $14,465
1 $14,784
9 $16,981
8 $17,286
5 $15,105
0 $9,451
5 $90,988
an administrin one transm
uantifiable dence results a
for the audile limits for).
8
tification Table
Dollar unt in ata
5,311.11
5,065.10
4,279.68
1,653.32
6,156.16
5,236.54
1,285.11
8,987.02
rator with mission),
degree of are a true
it period, r denials
e
Sect
ion III – UHCC’s Repport Reesponsse
9
City of Milwaukee Initial External Audit Response Report
Tuesday, August 13, 2013
2 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Table of Contents
Introduction Page 3
Executive Summary Page 4 - 6
Driving Process Improvements Organizationally Page 7
Random Medical Claim Audit : Claim Review and Remediation Plan Page 8 - 10
– Agreed to Errors
Focused Medical Claim Audit: Claim Review and Remediation Plan Page 11 - 13
– Agreed to Errors
Medical Claim Findings and Recommendations Page 14 - 15
Conclusion Page 16
Appendix A: Table of Error Findings: Random Medical Claim Audit Page 17 - 18
Appendix B: Table of Error Findings: Focused Medical Claim Audit Page 19 - 20
3 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Introduction
• City of Milwaukee engaged the services of The Segal Company (Segal) to perform both a random medical claim audit and a focused medical claim audit during the week of July 8, 2013. We have received a copy of the audit report, including any analysis of the findings and recommendations for improvement.
• Within the following pages you will find the UnitedHealthcare, Employer and Individual (UnitedHealthcare) initial response to the audit findings.
• Our response is intended to detail:
– our initial findings to the recently received auditor’s report
– what action steps have already been taken
– additional action steps that will be taken to complete our remediation process
• In addition, we would like to plan a meeting date to:
– discuss our final audit response which will include updates to our current findings and final disposition of each issue identified in this audit
– supply you with additional detail around our ongoing corporate quality improvement initiatives
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Medical Claim Review – Executive Summary
Summary of Audit:
Population Sample Size Extract Period Audit Location Date Audit Performed
City of Milwaukee
Medical Benefit Plan
(Random Audit)
75 Claims
January 1, 2012
through
December 31, 2012
Oldsmar Florida Transaction Center
Week of
July 8, 2013
City of Milwaukee
Medical Benefit Plan
(Focused Audit)
15 Claims
January 1, 2012
through
December 31, 2012
Oldsmar Florida Transaction Center
Week of
July 8, 2013
• As with all audit data, UnitedHealthcare clearly recognizes that Segal’s findings are meaningful and represent opportunity for continued improvement in our processing and administration of the City of Milwaukee benefit plan.
• A detailed listing of all sample items can be found in both Appendix A and B of this document.
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Medical Claim Review – Executive Summary
Performance Category Statistical Achievement Industry Standard
Financial Accuracy (dollar value) **100.00% 99.00%
Claims Processing Accuracy (overall incidence) **99.86% 95.00%
Payment Accuracy (incidence) **100.00% 97.00%
Processing Timeliness (within 10 business days)* **98.72% 90.00%
• The preliminary results of the random medical claim audit are reflected in the table below.
*Based on 14 calendar day measurement **Met or exceeded industry standard
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Medical Claim Review – Executive Summary
Status Source Detail Random Audit
In-Sample Volume
Random Audit
Out-of-Sample
Volume
Random Audit
Sample Numbers
Focused Audit
In-Sample Volume
Focused Audit
Sample Numbers
Agreed to Error Manual Adjudication 1 1 46, oos64 3 1, 4, 5
Agreed to Error Systems 0 0 Not Applicable 1 8
• UnitedHealthcare analyzes audit data on many levels to drive remediation not only at the specific customer level, but also for our global initiatives. Opportunities identified through our functional real time quality programs, focused claim audits, external audit findings, and our end to end process audits are combined and prioritized using a standard categorization. • We have performed both a root cause and group impact analysis on the errors identified during this audit. We have found the following error categories are indicated:
7
Driving Process Improvement Organizationally
Remediation Plans 2013
Individual / Departmental Plans Corporate Initiatives
Manual Where applicable:
• Feedback and refresher training provided to the responsible processor
• Training materials updated and enhanced
• Policies and Procedures updated to ensure quality
• Business Process updated and enhanced
• Quality Programs implemented or revised as needed
• Implementation of Individual processor incentive compensation programs
• Functional teams develop Individual Client Specific Remediation plans as necessary
• Pipeline report that reflects and prioritizes root cause impact across quality programs, which allows us to determine high priority projects
Benefit • Enhanced formalized defect reduction plan to address trends. Include a cross-functional team to review benefit capture and benefit coding opportunities
Provider • Improved accountability using real-time information and feedback
• Evaluation and remediation to the rate correction process
System • Reduce duplicate claim volume
• Reduce co-pay adjustments
A High Level View of the Process….implementing solutions at the root cause!
Our all-inclusive approach allows us to work together in order to improve processes and ultimately your outcomes.
Organizational Department
Employer and Broker Ops
UnitedHealth Networks
Transactions
Care Coordination
Medical Policy
System
Customer Care
Optum Health
Account Management Team
Group Enrollment
Member Enrollment Benefit Set up
Custo
mer
Setup
Prov
ider
Set u
p
CredentialingDemographic
Set up
Contract Creation/
Configuration (Fee Schedules)
Authorization Referral Intake
Utilization Management(Med Mgmt)Pa
tient
Mana
geme
ntCl
aim
Proc
essin
g
Outbo
und
Cons
tituen
t Co
mmun
icatio
n
Comm
unica
tion
Communication to Constituent
Billing
Claim Intake
Auto Claim Adjudication Summary
Check
ID Card SOB Certificate
Claim Adjustments
Claim Appeals
Manual Claim Adjudication
Care Cooridnation
Provider Data Maintenance
Pricing
Member/ Provider Calls
Broker/ Group Calls
IRUIssue
Resolution Unit
RRERapid
ResolutionUnit
SAM EDITS
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Claim Review and Remediation Plan Random Medical Claim Audit
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Agreed to Findings
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Agreed to Error Review
Sample 46 Error Source: Manual Adjudication Type of Error: Procedural
Impact to DAR: 0.00% Impact to CPA: 0.00% Segal Report Pages 1 & 6
Error Description UnitedHealthcare agreed to a procedural (non-payment) error when the claim payment processor denied the claim and requested a copy of the Medicare Explanation of Benefits in error.
Corrective Action • Sample claim was corrected on 06.01.2012.
• Feedback and refresher training were provided to the claim payment processor on 08.06.2013.
Out-of-Sample 64 Error Source: Manual Adjudication Type of Error: Financial
Impact to DAR: Not Applicable Impact to CPA: Not Applicable Segal Report Pages 1 & 6
Error Description UnitedHealthcare agreed to an underpayment of $68.40 when the claim payment processor applied the incorrect coinsurance (70% versus 100%) for professional services rendered during an inpatient confinement.
Corrective Action • Out-of-sample claim was corrected on 08.01.2013.
• Feedback and refresher training were provided to the claim payment processor on 08.06.2013.
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Claim Review and Remediation Plan Focused Medical Claim Audit
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Agreed to Findings
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Agreed to Error Review
Samples 1, 4 and 5 Error Source: Manual Adjudication
Sample Category: Duplicate Payments Segal Report Pages 2 & 6
Error Description UnitedHealthcare agreed to overpayments of $813.34, $836.73 and $1,737.55 respectively when the claim payment processors allowed duplicate charges to be paid in error.
Corrective Action • Sample 1 was corrected on 08.01.2013. Recovery efforts will not be initiated due to provider contract language. The check issue date for this claim is greater than 12 months for this in-network provider.
• Sample 4 was corrected and the overpayment of $836.73 was recovered and credited back to the City of Milwaukee on 07.25.2013.
• Sample 5 was corrected on 07.31.2013 with an overpayment request to the provider of service. Recovery efforts are underway.
• Feedback and refresher training were provided to the claim payment processors on 08.06.2013.
Sample 8 Error Source: Systems
Sample Category: Duplicate Payments Segal Report Pages 2 & 6
Error Description UnitedHealthcare agreed to an overpayment of $2,772.01 when the claim payment system allowed duplicate charges to be paid in error.
Corrective Action • Claim payment system correction is scheduled for 3rd Quarter 2014.
• Smart Audit Master (SAM) Edit Rule 1765 was activated to capture and report this system limitation until the global system fix can be completed.
• Sample claim was corrected on 08.01.2013 with an overpayment request to the provider of service. Recovery efforts are underway.
• A meaningful systemic Impact report for this error is not obtainable.
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Medical Claim Findings And Recommendations
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Segal Recommendation Segal Recommendation UnitedHealthcare Response
• UHC should generate system analysis to identify and validate additional duplicate payments during the audit period. Results should be provided to the City to determine the financial impact to the Plan. (Targeted Sample, Page 2 and Exhibit A, Error Listing, Page 6)
UnitedHealthcare’s standard process is to run impact reports on the errors that would have a repeatable impact to the population to identify the exact dollars impacted from an audit. An example of 'Repeatable impact' would be benefit related errors where UnitedHealthcare set up the benefit incorrectly (i.e. have the wrong copay set up). Our process would be to have the system corrected, pull all the impacted claims from history, determine the mispayment amount and make the corrections to the customer's files. We provide updates to the customer as the remediation process continues and we determine these impacts and work to resolve these for the customer. Manual adjudication errors (i.e.: human error) are handled as single events as the error was due to an individual making an error on a single claim.
• UHC should provide examiner retraining to stress the importance of accurate claim history investigation when the system attaches a potential duplicate claim edit to a claim. (Targeted Sample, Page 2 and Exhibit A, Error Listing, Page 6)
Feedback and refresher training regarding the error conditions has been reviewed with the responsible processors as outlined in the preceding pages of this report.
• The underpayment should be reopened and additional payments sent to the employee and/or provider with an explanation. Refund recovery for the identified overpayments should be issued based on the City’s direction. (Exhibit A, Page 6)
In the preceding pages of this report, each sample error cited by Segal has been thoroughly reviewed and the root cause along with remediation efforts to reduce similar occurrences has been discussed in detail. The UnitedHealthcare Account Management Team will report back to City of Milwaukee quarterly with the amounts recovered from the requested overpayments.
• UHC should advise the City of Milwaukee of any modification to system programming or changes in adjudication procedures resulting from this review.
The UnitedHealthcare Account Management Team will be happy to discuss modifications to system programming with City of Milwaukee that are a direct result of this review.
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Conclusion
• UnitedHealthcare is committed to our partnership with the City of Milwaukee
and appreciates the work performed by Segal on their behalf to identify areas of opportunity relative to the targeted sample categories.
• UnitedHealthcare will continue to work aggressively to ensure that all corrections are made and all remediation completed.
• The UnitedHealthcare team looks forward to a continued partnership as we strive to provide you with the best service in the industry.
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Appendix A: Random Medical Claim Audit Table of Error Findings
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Table of Error Findings and Decisions
Sample Decision Source Detail
Error Type
Sample Financial Impact
Sample Financial
Status
Estimated Group Financial Impact
Group Financial Status
46 Agree Manual Adjudication
Procedural $0.00 Sample Corrected Not Applicable Not Applicable
oos64 Agree Manual Adjudication
Financial ($68.40) Sample Corrected Not Applicable Not Applicable
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Appendix B: Focused Medical Claim Audit Table of Error Findings
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Table of Error Findings and Decisions
Sample Decision Source Detail
Error Type
Sample Financial Impact
Sample Financial
Status
Estimated Group Financial Impact
Group Financial Status
1 Agree Manual Adjudication
Financial $813.34 Sample Corrected No Recovery > 12 mos.
Not Applicable Not Applicable
4 Agree Manual Adjudication
Financial $836.73 Sample Corrected Recovered and Credited
Not Applicable Not Applicable
5 Agree Manual Adjudication
Financial $1,737.55 Sample Corrected Recovery Underway
Not Applicable Not Applicable
8 Agree Systems Financial $2,772.01 Sample Corrected Recovery Underway
Not Applicable Not Applicable