Audit of Medical Claims Processed by United...

Audit of Medical Claims

Processed by

United Healthcare, Inc.

MARTIN MATSON City Comptroller

AYCHA SIRVANCI, CPA Audit Manager

City of Milwaukee, Wisconsin

March 2014

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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

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sis of CaymenPeriod

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ber 16, 2

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sulting Washingtozona 85281

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waukee

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Mitc Rut Seg 101 Chic 312

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ch Bramsta a

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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 ..................

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.....................

ysis ................

s ...................

Response .....

t s

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................. 4

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................. 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 - 18

Appendix B: Table of Error Findings: Focused Medical Claim Audit Page 19 - 20


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


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.



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



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


Claim Review and Remediation Plan Random Medical Claim Audit


Agreed to Findings


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.


Claim Review and Remediation Plan Focused Medical Claim Audit


Agreed to Findings


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.


Medical Claim Findings And Recommendations


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.


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.


Appendix A: Random Medical Claim Audit Table of Error Findings


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


Appendix B: Focused Medical Claim Audit Table of Error Findings


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


Financial $813.34 Sample Corrected No Recovery > 12 mos.

Not Applicable Not Applicable


Financial $836.73 Sample Corrected Recovered and Credited



Financial $1,737.55 Sample Corrected Recovery Underway


8 Agree Systems Financial $2,772.01 Sample Corrected Recovery Underway


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