Audit of Medical Claims Processed by United …

1 Audit of Medical Claims Processed by United healthcare , Inc. MARTIN MATSON City Comptroller AYCHA SIRVANCI, CPA Audit Manager City of Milwaukee, Wisconsin March 2014 CCUAaFJFSS LAS1T66 Copyright 2013 City oUNITEA nalysand PaFor the PJanuary Final ReSeptembSubmitted Lynda A. ShAdministratSegal Cons1230 West Tempe, Ariz602-381-40602-532-76 3 by The Segal Gf MilwED HEsis of CaymenPeriod 1 througeport Reber 16, 2By heldon, HIAion and Tecsulting Washingtozona 85281046 654 Group, Inc.

2 All rigwaukeeEALTC laimsnt Procgh Decemeleased 2013 A chnology C n Street, S1-1248 ghts reserved. e THCARs Procecedurember 31,Consultinguite 501RE essinges , 2012 Mitc Rut Seg 101 Chic 312g ch Bramsta ah Donahuegal Consulti North Waccago, IL 602-984-8500aedt, 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.

3 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. TabCity of Final ReSeptembSSS le ofMilwaukeeport Releasber 16, 2013ection I ExeScope of SStatistical Targeted SRecommeection II ClaIndividual Premium PSelection oTurnarounClaim Conection III Uf Conee sed ecutive SummServices.

4 AchievementSample ..ndations ..aims Audit ReClaims ReviePhysicians ..of Claims ..d Time Analyntrol MeasuresHC s Report Rntentmary ..t ..eview ..ew ..ysis ..s ..Response ..ts .. 9i SectThis repoUnited Hbenefits. during thScope A data Decembeprovidedcompone An A A strstatis A tardupliThe audidocumenclaims adWorksheStatistOf the PaymenProcess*100% eleion I ort analyzesHealthcare (U Lynda Shehe week of Ju of Servicfile of all er 31, 2012,d by UHC ents: Adjudication ratified samtical validityrgeted samplicate paymenitor completntation on whddressed witeet number intical Achi5 stratified c.)

5 An Other nce was excon of statistiCal Accuracy Processing Ant Accuracy ing Timelinectronic calcula Execus and evaluaUHC) in theeldon conduculy 8, 2013. ces Medical cl, representinfor our samReview to ample of 75 cy with comple of Claims nts. ted a form fhich our repothin this repndicates the ievementclaims auditClaim Mattceeded; this ical achievemCategory (dollar value) Accuracy (ov(incidence) ess (within 10 ation based on utive Sates the claieir administrcted the ons laims proceng $90,988,9mpling purpassess claim Claims totaliarison to indto provide rfor each claiort is are refersample is a t ed, 74 were ter is noted is noted forments.)

6 Performanverall incidencebusiness days14 calendar daSummams processiration of thesite review assed in beoses. Our control meaing $1,135,2dustry standarepresentatioim sample s Due to the rred to as Wtarget samplprocessed won an out-or informationce MeasurStAch10e) 910)* 9ay measuremenary ing and paye City of Miat UHC s Olg the Audit enefit paymeclaims revasures; in bards; and on of selecteelected; thisconfidentialWorksheets. le erroof-sample clonal purposerement atistical hievement nt.

7 Yment procedilwaukee s gldsmar, Florperiod Janents on 239view includebenefit paymed benefit tys worksheet lity of name The letteror. One procaim where tes and is noIS9999dures utilizegroup healthrida Claims onuary 1 thr,086 claimsed the folloments to proypes and potewas the pries, diagnosisr T precedincedural errorthe calendarot included industry tandard 1ed by h plan office rough , was owing ovide ential imary , etc., ng the r was r year in the Based oncategory TurnarouA basic pof all clastratum.

8 Comparissample pIndustry by majoperformaemployerTargetFifteen tapotential following P T H A D Rw BOur elecselected services, paid baseThe remaelectroniOnsite reduplicateadjustmethe systemSegal recpaymentsfinancial n the statisduring theund time is pprinciple of aims; therefo The total son to indusproduces a 90standards arr carriers aance for admr plan benefited Sampargeted claimdiscrepancig areas: hysical TherTemporomanHearing aids Acupunture, aDental care oRoutine foot with a severe Biofeedback ctronic analyfrom specifdiabetic maed on Plan baining eight c analysis oeview of cles were exents).

9 Basedm edit durincommends Us during theimpact to thtical findinge benefit yepresented in Ethe samplingore, the respeprojected estry standard0% confidenre developedand third paministration fits. le ms were inclies based orapy servicendibular Joinfor ages 19 aacupressure,ther than thocare (cuttinsystemic diservices yses did nofic claim typanagement ienefits. Claims seleof 100% of laims documxplained ( on our findng processingUHC generate Audit periohe Plan. Seggs, UHC s ear. Error Exhibit B; thg technique ective strataerrors are uds.))

10 With ance level witd through onarty adminisof fully-insluded as partn calendar s exceeding nt treatment eand older , massage those identifiedg or removasease or indiot identify apes not reprtems, ostomcted for revfclaims. Fmentation ane., differendings, all errog. te a system od. Resultsgal also recoachievemendetails are he stratificatis that the sterror rate issed to calcun observed h 5% precingoing reviestrators natisured and set of the revieyear benefi50 visits exceeding $herapy servicd under Denal of corns, ividuals withany potentiaresented in my supplies);iew were idour duplicand UHC rent providersors resulted fanalysis to is should be ommends UHnt exceeded included intion table is Etratified auds used to proulate the sterror rate oision.