5. Health Claim Auditors, Inc. quarterly audit of HealthSCOPE

Transcription

5.
5.
Health Claim Auditors, Inc. quarterly audit of
HealthSCOPE Benefits (HSB) for the timeframe
January 1, 2016 – March 31, 2016.
(For Possible Action)
5.1. Report from Health Claim Auditors.
(Robert Carr III, Health Claim Auditors)
5.2. HealthSCOPE Benefits response to audit
report. (Mary Catherine Person, HSB)
5.3. Accept audit report findings and assess
penalties, if applicable, in accordance with the
performance guarantees included in the
contract pursuant to the recommendation of
Health Claim Auditors.
5.1.
5.
January 1, 2016 – March 31, 2016.
5.1. Report from Health Claim Auditors.
(Robert Carr III, Health Claim Auditors)
Claims and System
Audit Report
for
Audit Period: PEBP Plan Year 2016, Quarter Three
January, February and March 2016
Audited Vendor:
Submitted By:
Health Claim Auditors, Inc.
May 2016
TABLE OF CONTENTS
Executive Summary
Procedures/Capabilities/Supporting Data
1-3
4 - 25
Introduction
4
Breakout of Claims
4
Payment/Financial Accuracy
5-6
History of Performance Guarantee Performance 6
Claim Payment Turnaround
6
Customer Service
7
Soft Denial Claims
9
Overpayments
10
Subrogation
12
Large Utilization
13
Dedicated Team Members
13
HSB System
13
HSB Policy/Procedure
14
Eligibility
14
Deductibles, Benefit Maximums
15
Unbundling/Rebundling
15
Concurrent Care
16
Code Creeping
16
Procedure, Diagnosis, Place of Service
16
Experimental/Cosmetic Procedures
16
Medical Necessity Guidelines
17
Patterns of Care
18
Mandatory Outpatient/Inpatient Procedures
18
Duplicate Claim Edits
18
Adjusted Claims
18
Hospital Discounts
18
Hospital Bills and Audits
19
Filing Limitation
19
Unprocessed Claim Procedures
19
R&C/Maximum Allowance
20
Membership Procedures
21
COBRA
21
Provider Credentialing
21
Coordination of Benefits
22
Medicare
22
Controlling Possible Fraud/Security Access
22
Quality Control/Internal Audit
23
Internet Capabilities
24
Communication, U/R and Claims Depts.
24
Claim Repricing
24
Banking and Cash Flow
25
Reporting Capabilities
25
General System
25
General Security
25
HCA Claim Audit Procedures
Specific Claim Audit Results
26
27 - 32
EXECUTIVE SUMMARY
Audited Random Selection Data
Total number of claims: 500
Total Charge Value of random selection: $ 789,719.59
Total Paid Value of random selection: $ 249,299.85
Performance Guaranteed Metric Results
Metric
Payment
Accuracy
Financial
Accuracy
Claim Processing
Turnaround Time
Customer
Service
Guarantee Measurement
> 97% of claims audited are to be paid
accurately
> 99% of the dollars paid for the audited
claims is to be paid accurately
- 90% of all claims processed within 18 days.
- 98% of all claims processed within 30 days.
-Telephone Response Time: < 30 seconds.
-Telephone Abandonment Rate: < 2%.
-Member Problems documented w/in 2 days
-Member Problem resolved within 10 days
Actual
Pass/Fail
98.80%
Pass
98.53%
99.74%
99.98%
29 sec.
1.96%
99.23%
97.25%
Fail
Pass
Pass
Pass
Pass
Pass
Pass
This audit detected twelve (12) identified types of errors (related to HSB operations
without network caused errors), a decrease of one (1) from the previous audit.
Issues identified within this audit/HCA recommendations (beyond common error
issues)
 Unpaid Services of Network Providers
At the time of this audit it remained a concern that claims billed from specific hospital
providers containing contract language for Revenue 390 (Blood Products) are not
being repriced by Hometown Health (HTH) and caused to be paid by HealthSCOPE
because invoices identifying the costs (as described within contract) are not received
from the providers. In late 2014, HTH stated that they formally informed the provider
of required data for correct adjudications, however, it was recommended that this
issue be addressed again by HTH for resolution or deleted from their contract with
this provider to prevent a more serious issue in the future. HTH informed HCA in
April 2016 that these contracts have been reopened for the purpose of a resolution to
this issue. HCA will report the outcome upon receipt from HTH.
HCA 05/16
Page 1
St.NV.PEBP/HSB 3rd Qtr PY 16
Previous Recommendation(s)
HCA is pleased to report that all recommendations accepted by the PEBP Board of
Directors has been implemented and/or in the process of application at the time of this
audit.
Primary Reasons for Financial Accuracy Underperformance
The HSB adjudication system is functioning at a high efficiency level, however, the
errors detected within the valid random selection which contributed to the majority of
the incorrect dollars paid within the Financial Accuracy metrics were within two (2)
manual application issues:
1) The incorrect application of Multiple Surgical Guideline reductions as they pertain
to American Medical Association (AMA) and Medicare rules;
2) The application of allowable rate reduction(s) for anesthesia services when both a
Nurse Anesthetist (CRNA) and an Anesthesiologist bill for the same session.
Recognition of Positive Action(s) by HSB
It is very typical throughout the United States in every audit to identify large dollar
claims that are considered Non PPO and/or those that have no Usual and Customary
Rates (UCR) or Reasonable and Customary (R&C) rates associated with the
service(s). This and previous audits have acknowledged numerous examples of HSB
conducting and seeking alternative methods to reduce egregious billings within this
issue. An example of these processes were found within this audit which included the
excessive billings of Air Flight service providers. Two (2) of these type claims were
billed to PEBP in excess of $577,000.00, of which a reasonable allowable was
approximately $32,000.00. HCA reviewed the methodology utilized for these
monetary reduction(s) and find that HSB should be congratulated on seeking the
appropriate resource expertise and applying reasonable adjudicating practices for
these claims beyond the efforts observed in most audits.
Trends/Issues
The audit revealed the following issues or trends detected from the random selection and
bias selected claims. Please note: the reference numbers in bold type are claims from the
random selection and are included within the statistical calculations. Reference numbers
in normal type were identified as issues in bias claims as defined earlier and are not
included within the statistical calculations of this audit. Specific information regarding
supporting reference numbers can be found in the Audit Results Section in numerical
sequence, which begins on page 27.
Incorrect rate applied;
Supporting reference no. 334
Paid medical service under routine benefits;
Supporting reference nos. 288 and 449
Procedure modifier (CRNA & Anesthesiologist) not applied;
Supporting reference no. 087 and 334B
HCA 05/16
Page 2
Services incorrectly bundled;
PPO Exception Rule not applied;
Claim denied in error;
Incorrect network utilized;
Claim not coordinated with Medicare;
Facility bill paid at incorrect coinsurance;
Paid under medical versus routine;
Bilateral surgical reduction not applied;
Dental UCR not applied;
The audit revealed the following issues, which appear to be administered properly
by HSB, but should be brought to client attention for proper notification or verification.
Specific information regarding supporting reference numbers can be found in the Audit
Results Section in numerical sequence, which begins on page 27.
SHO updated fee schedule received 1/21/16;
Supporting reference nos. 111, 116, 145, 213, 499 and 500
Mammogram with medical diagnosis paid at 100% as first plan
year benefit;
Medicaid reclamation claim for PPO provider processed and paid
as out-of-network;
Possible system display error;
Application of Multiple Surgical Guidelines (bilateral reductions) to primary
service codes with percentage off contract rates;
HCA 05/16
Page 3
CLAIM PROCEDURES/
SYSTEM CAPABILITIES/SUPPORTING DATA
Introduction
In April 2016, Health Claim Auditors, Inc. (HCA) performed a Claims and System Audit
of HealthSCOPE Benefits (HealthSCOPE) located in Little Rock, Arkansas on behalf of
The State of Nevada Public Employees’ Benefits Program (PEBP).
This audit was performed by collecting information to assure that HealthSCOPE is doing
an effective job of controlling claim costs while paying claims accurately within a
reasonable period of time.
This report was presented to HealthSCOPE for any additional comments and responses
on 25 April 2016.
Breakdown of Claims Audited
The individual claims audited were randomly selected from PEBP’s claims listings as
supplied by HealthSCOPE. These claims had dates of service ranging from April 2015 to
March 2016 and were processed by HealthSCOPE from 01 January 2016 through 31
March 2016 (PEBP’s Third Quarter Plan Year 2016). These claims were stratified by
dollar volume to assure that HCA audited all types of claims. The audit also includes
large dollar paid amounts that are considered as bias* selected claims.
*Bias claims are not part of the random selection but were audited by HCA because of
some “out of the ordinary” characteristic of the claim. There are multiple criteria to
identify the “out of the ordinary” characteristics. Examples are duplicates, CPT up
coding, exceeding benefit limits, etc.
The breakdown of the 500 random selected claims audited is as follows:
Type of Service
Medical
Outpt. Hospital
Inpt. Hospital
Dental
TOTAL
HCA 05/16
Charge Amount
Paid Amount
Paid Distribution
No. of Claims
$ 247,840.20
$ 353,661.23
$ 109,899.66
$ 78,318.50
$ 789,719.59
$ 71,334.42
$ 103,595.72
$ 39,089.95
$ 35,279.76
$ 249,299.85
28.6%
41.5%
15.7%
14.2%
100%
282
39
3
176
500
Page 4
Payment Accuracy
Per PEBP, the Service Performance Standards and Financial Guarantees Agreement for
the payment accuracy is to be 97% or above of claims adjudicated are to be paid correctly
or a penalty of 2.5% of Quarterly Administration Fees for each percent (%) point, or
fraction thereof, below performance guarantee is to be applied. Payment Accuracy is
calculated by dividing the total number of claims not containing payment errors in the
audit period by the number of claims audited within the random selection.
The Payment Accuracy Percentage of the number of claims paid correctly from the
HealthSCOPE random selection for this audited quarter is 98.8%.
Number of claims:
Number of claims paid incorrectly:
Percentage of claims paid incorrectly:
Number of claims paid correctly:
Percentage of claims paid correctly:
500
6
1.20%
494
98.80%
Payment Accuracy for the past four quarters
Financial Accuracy
Per PEBP, the Service Performance Standards and Financial Guarantees Agreement for
the financial accuracy of the total dollars paid for claims adjudicated is to be paid
correctly at 99% or above or a penalty of 2.5% of Quarterly Administration Fees for each
percent (%) point, or fraction thereof, below performance guarantee is to be applied.
Financial Accuracy is calculated by dividing the total audited dollars paid correctly by
the total audited dollars processed within the random selection.
The Financial Accuracy Percentage of paid dollars remitted correctly on the
HealthSCOPE claims selected randomly for this audited quarter is 98.53%.
This audit reflected forty-six and four tenths percent (46.4%) of the audited errors within
the valid random selection were overpayments.
Paid dollars audited
Amount of paid dollars remitted incorrectly
Percentage of Dollars paid incorrectly
Paid Dollars of claims paid correctly
Percentage of Dollars Paid correctly
HCA 05/16
Page 5
$ 249,299.85
$ 3,656.52
1.47%
$ 245,643.33
98.53%
Financial Accuracy for the past four quarters
Historical Statistical Data of Performance Guarantees
The following reflects the historical statistical data since the origin of PEBP medical
claims administration by HealthSCOPE. The entries designated in bold red type are
measurable categories below the Service Performance Guarantees Agreement.
Period Audited
st
1 Qtr PY 2012
2nd Qtr PY 2012
3rd Qtr PY 2012
4th Qtr PY 2012
1st Qtr PY 2013
2nd Qtr PY 2013
3rd Qtr PY 2013
4th Qtr PY 2013
1st Qtr PY 2014
2nd Qtr PY 2014
3rd Qtr PY 2014
4th Qtr PY 2014
1st Qtr PY 2015
2nd Qtr PY 2015
3rd Qtr PY 2015
4th Qtr PY 2015
1st Qtr PY 2016
2nd Qtr PY 2016
3rd Qtr PY 2016
HCA 05/16
Payment
Accuracy
Financial
Accuracy
Turnaround
Time
Telephone
Telephone
Response
Abandon Rate
95.7%
93.3%
96.8%
95.8%
97.2%
98.5%
98.0%
98.4%
98.8%
99.2%
98.0%
99.0%
98.8%
99.0%
98.6%
99.6%
99.0%
98.6%
98.8%
98.6%
97.3%
98.6%
99.5%
99.4%
99.3%
95.7%
99.7%
99.6%
99.2%
98.5%
99.8%
99.27%
99.35%
99.8%
95.6%
98.9%
99.7%
98.53%
7.6 days
12.7 days
3.7 days
11.4 days
10.4 days
7.3 days
6.4 days
6.2 days
5.4 days
5.9 days
5.2 days
4.4 days
4.9 days
8.1 days
5.9 days
4.9 days
4.8 days
3.5 days
5.3 days
:17
:12
:18
:14
:20
:11
:25
:29
:14
:29
:30.5
:28
:29.4
:22
:29.7
:29.4
:29.1
:24.0
:29.0
1.43%
1.16%
1.32%
0.93%
1.06%
0.87%
1.98%
1.61%
0.84%
1.96%
1.92%
1.96%
1.94%
1.18%
1.97%
1.91%
1.94%
1.14%
1.96%
Page 6
Turnaround Time
Per the Service Performance Standards and Financial Guarantees Agreement, the
turnaround time for payments of claims is measured in calendar days from the date
HealthSCOPE receives the claim until the date of process. Ninety percent (90%) of all
claims are to be processed within eighteen (18) calendar days and ninety nine percent
(99%) are to be processed within thirty (30) calendar days or a penalty of two percent
(2.0%) of Quarterly Administration fees for each percentage point or fraction thereof in
non-compliance per level is to be applied. HCA had requested the report that reflects the
measurement of this issue. This report reflected that 99.74% of “clean” claims were
processed within 18 calendar days and 99.98% of “clean” claims were processed within
30 calendar days, in compliance with the performance guarantee. This report also
displayed the total turnaround process time for all claims at 3.7 business days.
Turnaround Time Measurements
The turnaround time, measured only from the random selected claims, for Medical claims
was 7.3 calendar days, Out Patient Hospital claims was 8.7 calendar days, In Patient
Hospital claims was 7.3 calendar days and Dental claims was 1.3 calendar days.
During the audit period of 01 January 2016 to 31 March 2016, HealthSCOPE had
received 810 PEBP e-mail inquiries for information via the internet. The average
turnaround time for these inquiries was less than 24 hours (24:00) with the exclusion of
those received on a holiday and/or weekend day.
Customer Service Satisfaction
telephone response time reflects all calls must be answered within thirty (30) seconds or a
penalty of one percent (1%) of Quarterly Administration fees for each second or fraction
thereof in non-compliance is to be applied. HCA has reviewed the appropriate report for
the PEBP third fiscal quarter Plan Year 2016, which revealed the average incoming
answer speed to be 29.0 seconds (0:29.0). The telephone response time was 30 seconds
for January 2016, 29 seconds for February 2016 and 28 seconds for March 2016.
Telephone Response Time (average)
HCA 05/16
Page 7
abandonment rate must be under two percent (2%) of total calls or a penalty of one
percent (1%) of Quarterly Administration fees for each percentage point or fraction
thereof in non-compliance is to be applied. Please note: this performance measurement
was changed from 3% as the measured benchmark for previous plan years. HCA has
reviewed the appropriate report for the PEBP third fiscal quarter Plan Year 2016, which
revealed the abandoned calls ratio to be 1.96%. The telephone abandonment rate was
2.43% for January 2016, 1.94% for February 2016 and 1.53% for March 2016.
Telephone Abandonment Rate
Per the Service Performance Standards and Financial Guarantees Agreement, ninety five
percent (95%) of incoming PEBP member problems must be documented within two (2)
business days and resolved within ten (10) business days or a penalty of one percent (1%)
of Quarterly Administration fees for each percentage point or fraction thereof in noncompliance is to be applied. HCA has reviewed the appropriate report for the PEBP third
fiscal quarter Plan Year 2016, which revealed that HealthSCOPE documented 99.23% of
problems within two business days and resolved 97.25% of problems within ten business
days.
HealthSCOPE has eighty plus (80+) Customer Service Reps (CSRs), of which, the
majority are in the Little Rock office with an average of eight (8) years experience.
Health SCOPE currently has eighteen (18) CSRs dedicated to the PEBP plan.
HealthSCOPE stated that customer service hours of operation will be applied to PEBP
direction for proper service levels.
Benefit data is supplied by electronic documentation so that the analyst may explain
benefit information to clients, members and providers by HealthSCOPE.
HealthSCOPE stated that the customer service representatives will not have the ability to
make system changes.
HealthSCOPE’s telephone conversations are documented for future reference.
HealthSCOPE does have an audit process for Customer Service Representatives.
HealthSCOPE is able to monitor trends/errors found through Customer Service.
HealthSCOPE can conduct customer service satisfaction surveys to determine employee
satisfaction of claims administration and service upon client request.
HCA 05/16
Page 8
Soft Denied Claims
The audit identifies the volume of claims adjudicated and placed in a “soft denied” status.
HCA recognizes and respects the need to place certain claims in a soft denied status such
as claims that require additional information or special calculation of payment. It is
HCA’s opinion that these amounts are the result of HealthSCOPE conducting due
diligence and resolution of the issues and trends including those previously detected in
previous audits. It is important to include this data within this report to disclose the
outstanding unpaid claims that could create an artificial debit/savings during the time that
these claims were adjudicated. Note: The measurement of this data was provided as a
“snapshot” report. The report reflected the “soft edit” amounts as they were reported on
the specific day that the report was recorded.
The report for the current claims placed in a “soft denied” status reflect a total of 2,871
claims representing $ 10,360,017.78
Soft Denied claims history:
Audit Period
Total Number of Claims
1st Qtr PY 2012
2nd Qtr PY 2012
3rd Qtr PY 2012
4th Qtr PY 2012
1st Qtr PY 2013
2nd Qtr PY 2013
3rd Qtr PY 2013
4th Qtr PY 2013
1st Qtr PY 2014
2nd Qtr PY 2014
3rd Qtr PY 2014
4th Qtr PY 2014
1st Qtr PY 2015
2nd Qtr PY 2015
3rd Qtr PY 2015
4th Qtr PY 2015
1st Qtr PY 2016
2nd Qtr PY 2016
3rd Qtr PY 2016
HCA 05/16
2,607
4,068
1,536
559
1,053
1,107
1,023
1,094
1,389
1,157
1,621
1.487
1,404
1,668
2,897
2,498
3,071
2,543
2,871
Charge Amount Value of Soft Edits
$ 7,544,177.55
$10,697,954.53
$ 6,472,249.56
$ 2,205,318.16
$ 3,413,738.12
$ 5,019,961.70
$ 4,179,542.34
$ 3,049,481.74
$ 3,853,629.07
$ 2,510,539.33
$ 7,873,432.21
$ 4,665,197.77
$ 5,901,903.17
$ 6,930,288.41
$10,800,874.08
$10,685,255.24
$13,027,717.82
$13,547,682.34
$10,360,017.78
Page 9
Overpayments
The previous PEBP health plan administrator (UMR) provided HealthSCOPE with
a report displaying the outstanding identified overpayments reflecting a grand total
of outstanding overpayments at $1,751,949.42. HealthSCOPE conducted much research
on these overpayments and found that 507 of these claims were deemed as no longer
valid due to providers showing items that were already paid to UMR, corrected claims
were sent to resolve the issue, etc. As of this audit, these aged overpayments
(overpayments aged in excess of four years) remain “on the books” as active, however,
are not displayed and reported as current overpayments.
HCA requested an overpayment report that reflects the identified current outstanding
overpayments incurred since the beginning of the contract period with HealthSCOPE.
This report reflected a current total of 3,360 (an increase of 207 from the previous report)
overpayments with a potential recovery value of $1,475,131.43 (a decrease of
$330,181.88) for HealthSCOPE. Detailed information regarding outstanding
overpayments can be reviewed in a separate Supplemental Report, which for
confidentiality purposes is not included in this report. It is made available to PEBP staff
should they request it.
During the audited period, HealthSCOPE recovered a total amount of overpayments for
an amount of $238,970.44 minus fees applied.
If an overpayment is detected by Health SCOPE, an overpayment refund request is
sent by the Overpayment Department. Follow-up on all overpayments is
conducted every thirty (30) days for three (3) letters.
If collection is not made after the 3 letters, collection rights are sent to their vendor with a
contingency fee as declared within their RFP 1983 response.
HealthSCOPE maintains an overpayment log and can supply this in report form.
HCA 05/16
Page 10
Of the 3,455 identified current outstanding overpayments (HSB only), 55.4% were
found to be caused by external sources that are not associated with the
HealthSCOPE adjudication processes. Breakout of the HealthSCOPE’s current
overpayments are listed by reason as follows:
% of all Error Type
18.39% Incorrect Benefit Applied
15.95% Corrected SHO Network Pricing/Feed
12.02% No COB on file
10.33% Incorrect Rate Applied
10.19% Provider caused, rebilled, charges billed in error, corrected EOB
8.47% Corrected Network pricing
5.47% Duplicate
4.39% Corrected HTH Network Pricing
3.17% COB incorrectly calculated or not applied
1.95% Processed under the incorrect provider
1.05% Industrial and/or possible Workers Compensation claim
0.99% Processed under incorrect patient
0.93% Paid after termination
0.79% Incorrect assignment applied
0.79% Exception/Appeal
0.76% Adjusted after medical review
0.64% Multiple Surgical Guidelines not applied
0.64% Services not covered under plan
0.55% Pharmacy claim deductible/Co-Insurance error
0.55% Exceeded maximum benefit limits
0.49% Paid PPO as NON PPO provider
0.47% Paid NON PPO provider as PPO
0.26% First Health Pricing Adjustment
0.20% Timely Filing
0.15% Incorrect units calculated error
0.12% Rental payments exceeded DME purchase price
0.09% Benefit Clarification
0.09% Subrogation error
0.06% Eligibility
0.03% Incorrect Pre-Certification applied
0.03% Paid Asst. Surgeon as Surgeon
HCA 05/16
Page 11
Subrogation
HCA requested a subrogation report that can be reviewed in a separate Supplemental
Report, which for confidentiality purposes is not included in this report. It is made
available to PEBP staff should they request it.
This report reflects open subrogation claims representing a current potential recovery
amount of $2,273,415.66; a decrease of $285,248.77 from the previous quarter.
Reports received from HealthSCOPE reflect that subrogation recoveries for the audited
period was $183,280.16. After contingency fees were paid, PEBP received $155,788.14.
HealthSCOPE system will apply a pursue and pay subrogation policy as directed by
PEBP. Per HealthSCOPE, subrogation is determined and pursued on all claims where the
total amount paid equals to or exceeds $1000 (one thousand).
HealthSCOPE stated that the claims system is automated to identify claims indicating a
diagnosis code (ICD-9) that could be related to subrogation situation.
HealthSCOPE does identify possible subrogation cases internally. HealthSCOPE utilizes
a third party vendor for recovery of monies. Vendors are paid a contingency of which the
administrator receives a portion of and disclosed within RFP 1983 for Third Party Claims
Administration.
HealthSCOPE does not conduct auditing of outstanding subrogation cases sent to
their vendors, but sends any cases not picked up by the main vendor to another
vendor for review.
HealthSCOPE depends on the external vendors to conduct the appropriate International
Classification of Diseases (ICD) sweep checks for subrogation detections. HealthSCOPE
is currently utilizing the new ICD-10 conversions and the coding has been completed
within their system.
Per HealthSCOPE, claims related to Worker’s Compensation are denied.
Recoupment and payments for subrogation claims are assigned as directed by PEBP.
HCA 05/16
Page 12
High Dollar Claimants
Per the request of PEBP staff, HCA has requested a report to identify the number
of active, retiree or COBRA elected participants or dependents who have
obtained a plan paid level of $750,000.00 or greater.
This report reflected forty-eight (48) members and sixteen (16) dependents for a total
of 64 active participants, who have obtained this level of plan payment participation
representing an accrued dollar paid amount of $88,766,125.04.
Personnel
The audit included a review of the HealthSCOPE personnel dedicated or assigned to
PEBP. The current Organization Chart for individuals assigned to the PEBP plan, is as
follows:
-
Claims Administration Vice President;
Account Managers, CHANGED, one added and one deleted for a total of 2;
Operations Support Director;
Provider Maintenance Specialist;
Financial Analysts;
Claims Administration Director;
Claims Administration Manager;
Claims Administration Supervisors; 2 individuals;
Claims Analysts, CHANGED, two individuals deleted for a total of 12 individuals;
Eligibility Director;
Eligibility Manager;
Eligibility Team Lead;
Eligibility Specialist, 2 individuals; CHANGED, one individual deleted for a total of
1 individual;
Customer Service Vice President (Ohio);
Customer Service Director;
Customer Service Representatives, CHANGED, four individuals added and four
deleted for a total of 18 individuals;
Correspondence Supervisor;
Correspondence Specialist, one (1); CHANGED, deleted from Organizational Chart
Scanning Specialist; CHANGED, deleted from Organizational Chart
Recoveries Supervisor;
Recoveries Specialists, 2 individuals;
Senior Data Analyst.
HealthSCOPE System Overview
The detailed reporting following this executive summary reflects the HealthSCOPE
system capabilities. The following issues have been identified as possible system
improvements. Note: Certain issues presented within the policy/procedures section may
be improved and/or corrected by possible system edit additions.
HCA 05/16
Page 13
The HealthSCOPE system does not electronically apply the reductions for situations
where multiple surgical (service modifier -51-) and bilateral (service modifier -50-)
services are provided. HCA recognizes and acknowledges that HealthSCOPE, through
intense internal training, has made significant improvements in processing claims with
multiple surgical (service modifier -51-) and bilateral (service modifier -50-) services.
The HealthSCOPE system is not automated to determine if anesthesia is billed by both
the hospital and anesthesiologist under both a revenue code and separate CPT service
code.
HealthSCOPE Policy/Procedures
The detailed reporting following this executive summary reflects the HealthSCOPE
policies and procedures. It was found during the administrator test audit and the current
claims and system audit that HealthSCOPE has developed and executes policies and
procedures as accepted within industry standards and qualification(s).
Eligibility
The HealthSCOPE system systematically denies claims for services rendered prior to or
after the effective date.
The HealthSCOPE system systematically adjudicates claims pertinent to the date of
service for those claims received prior to or after any benefit changes.
The HealthSCOPE system has the capability to load by line of coverage tiers (i.e.: single
medical/family dental, etc.).
HealthSCOPE can, if requested, request divorce decrees or court orders for those
dependents of divorced or separated parents.
The HealthSCOPE system will enforce IRS regulations if the Plan Document does not
require stricter requirements.
Disabled (handicapped) dependent status is determined by PEBP when a covered
dependent child has reached the age of 26, which would terminate his/her status as a
dependent. HealthSCOPE can determine disabled dependent status with internal medical
personnel if required.
HealthSCOPE has stated that they would not ever add a member dependent without
PEBP authorization.
HealthSCOPE stated that the turnaround time to add or delete a member’s eligibility is
within 24 hours of receipt.
If a member is terminated retroactively, HealthSCOPE will review that member’s claim
history to determine any overpayments for possible recoveries and proceed per PEBP
instructions.
HCA 05/16
Page 14
Deductibles, Out-of-Pocket and Benefit Maximums
The HealthSCOPE system is capable of separate PPO and Non PPO accumulators.
All deductibles, out-of-pocket expenses and most benefit maximums are tracked by the
HealthSCOPE system.
The HealthSCOPE system contains automated carry over deductible features if
necessary.
HealthSCOPE system contains integrated deductibles for dental and medical claims.
HealthSCOPE does have experience of applying the Prescription Drug and Medical
claims deductibles as reflected within the PEBP SPD.
Unbundling/Rebundling
The HealthSCOPE system can systematically edit to identify laboratory, diagnostic and
radiology charges that have been unbundled and billed separately.
The HealthSCOPE system has the electronic capacity to match multiple claims in history
for application of the unbundling edit.
The HealthSCOPE system systematically soft edits for multiple surgical guidelines, for
those situations where a surgeon is billing for more than one (1) surgical procedure
during the same operative session. The HealthSCOPE system has the capacity to match
claims in history for application of the multiple procedure reduction edit.
For Network providers and Non-PPO providers where multiple surgical procedures have
been performed, the HealthSCOPE system will electronically adjudicate and apply 100%
of the Reasonable and Customary (R&C) or the provider specific fee schedule amount for
the major procedure, 50% of the R&C or network fee schedule amount for subsequent
procedures or any deviation designed by the network contract. This application is
conducted manually with HealthSCOPE. The system can calculate the claim by global or
individual allowance accounting.
For Network providers and Non-PPO providers where bilateral surgical procedures have
been performed, the HealthSCOPE system will not electronically adjudicate to allow
100% of the Reasonable and Customary (R&C) or the provider specific fee schedule
amount for the major procedure and 50% of the R&C or network fee schedule amount for
the secondary procedure. This application is manually applied.
HealthSCOPE manually breaks this issue into separate line services for adjudication.
The HealthSCOPE system is automated to identify pre/post operative care related to
surgical procedures.
The HealthSCOPE system denies incidental procedures when in relation to primary
procedures.
HCA 05/16
Page 15
The HealthSCOPE system systematically identifies claims that contain a same day
procedure (procedures that are not customarily billed on the same day as a surgical
procedure) unless billed under the same provider.
HealthSCOPE will allow the doctor to bill the initial obstetrical diagnostic office visit.
The subsequent visits are paid and then manually tracked and applied to the global
obstetrical fee. Reasonable and Customary (R&C) allowance or network fee schedule
amount is applied to the global obstetrical fee. Obstetrical lab and diagnostic procedures
are allowed to be billed separately.
Concurrent Care
The HealthSCOPE system is not automated to identify situations where more than one
(1) physician is billing for services during the same time period for the same diagnosis.
The claims analysts rely on the system’s possible duplicate edit to detect this situation.
Code Creeping
The HealthSCOPE system is automated to identify code creeping. An example of this
occurs when a physician is consistently billing for an initial or new patient office/hospital
visit when services performed are actually rendered for a subsequent or established
patient visit.
Procedure, Diagnosis and Place of Service
The HealthSCOPE system is automated to determine the correct usage of the Current
Procedural Terminology (CPT) code. The system is automated to edit if the patient’s age
or gender does not concur with the (CPT) code.
The HealthSCOPE system edits if multiple CPT codes that are billed on the same claim
don’t belong together.
The HealthSCOPE system is automated to identify if the place of service does not concur
with the (CPT) code.
The HealthSCOPE system is also automated to edit if a diagnosis does not concur with
the (CPT) code.
The HealthSCOPE system has the capability to edit for routine/medical diagnosis’ to
determine which benefits are allowable under routine versus medical.
Experimental and Cosmetic Procedures
The HealthSCOPE system is automated to assist processors in identifying those
procedures that are or could be cosmetic. Analysts are also trained to identify these
claims. These procedures can also be identified during the pre-certification process.
The HealthSCOPE system can be programmed to systematic hold or deny these types of
claims, depending upon plan election.
HCA 05/16
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Medical Necessity/Potential Abuse Guidelines and Procedures
The HealthSCOPE system is automated to determine the appropriateness of an assistant
surgeon based on the surgery performed. These claims can be pended or denied,
depending upon the plan election.
The HealthSCOPE system is automated to determine the appropriateness of an
anesthesiologist based on the service performed. These claims can be held or denied,
depending upon the plan election.
The HealthSCOPE system is not automated to determine if anesthesia is billed by both
the hospital and anesthesiologist under both a revenue code and separate CPT service
code.
HealthSCOPE determines medical necessity for the rental or purchase of durable medical
equipment (DME) by prescription from a physician or internal Medical Reviewers.
Rental cost of DME is not systematically tracked up to the purchase price by
HealthSCOPE to assure that PEBP will pay no more for rental than it would if this
equipment had been purchased. HealthSCOPE tracks this issue on a manual basis within
their system.
HealthSCOPE investigates to determine if a prescription is a federal legend drug. They
utilize the Medi-Span database for this procedure.
Claims involving chiropractic care, physical therapy are determined for medical necessity
by HealthSCOPE. Therapeutic treatment needs to be rendered by a licensed physical
therapist. Treatment must be commonly and customarily recognized as appropriate within
the doctor’s profession.
Per HealthSCOPE, medical necessity for infusion services are usually determined by
Utilization Review but can be determined internally if necessary.
The HealthSCOPE system can comply with authorization, repricing and all requirements
as they pertain to adjudication of Mental Health claims.
HealthSCOPE does execute on a regular basis, daily exception reports, which are run for
supervisors to review edits that are overridden.
The HealthSCOPE system has the capability to identify repeat tests being done by both
primary physicians and specialists.
HCA 05/16
Page 17
Patterns of Care and Treatment for Physicians
HealthSCOPE has the capability to conduct evaluations of patterns of care of physicians
on patient outcome studies (success) for various procedures and communicate facts to
physicians to eliminate unnecessary or ineffective care or disclose potential fraud or
trends of fraud.
Mandatory Outpatient/Inpatient Procedures
The HealthSCOPE system is not automated to determine those procedures that do not
require hospitalization. Pre-certification is required for an inpatient stay and many
surgical procedures, of which, most procedures will be identified at that time.
Duplicate Claim Edits
The HealthSCOPE system is automated to identify duplicate claims. The HealthSCOPE
system will “soft” edit a claim under partial match and a “hard” edit under exact match
circumstances. The following criteria are matches: Date of Service, CPT including
modifier and Provider tax identification number.
In the event of multiple provider submissions, the PEBP member will receive an
Explanation of Benefits (EOB) for all claims paid.
Adjusted Claims
In the event that a claim was previously paid and an adjustment is made to the original
adjudication, the HealthSCOPE system will assign a “claim identification number” to the
adjustment that reflects the original paid claim. HealthSCOPE links the original with the
adjusted claim(s) with a notation on subsequent claim screens.
Hospital and Other Discounts
HealthSCOPE can automate all PPO Provider discounts including per diem and
Diagnosis Related Group (DRG) arrangements.
HealthSCOPE stated that PPO (Preferred Provider Organization) provider rates which
can be obtained can be repriced in-house.
If a network has negotiated a prompt payment discount, the HealthSCOPE system is
programmed to apply the discount.
HCA 05/16
Page 18
Attempts to negotiate non-PPO provider discounts are conducted by HealthSCOPE’s
vendors, with contingencies as reported within the response to RFP 1893. PEBP can set
this issue at as low as $0 for HealthSCOPE.
HealthSCOPE declared that they do not collect any year end settlements, rebates, etc.
other than those declared within their response(s) to RFP 1893.
HealthSCOPE stated that they would review and disclose any provider discount contracts
relative to PEBP claims for the absence of any “Hold Harmless” language as an aid in
protecting PEBP members.
Hospital Bills (UB-92) and Audits
HealthSCOPE requires itemized hospital bills to determine non-covered items.
Itemization for all hospital bills over $10,000.00 is required by HealthSCOPE to
determine non-covered items.
The HealthSCOPE system utilizes revenue codes when processing hospital bills.
HealthSCOPE has an internal hospital audit program in place. All non-PPO claims over
$50,000.00 are sent for audit. HealthSCOPE also stated that some claims are audited
through their external audit process. HealthSCOPE is willing to accept any amount PEBP
determines as a minimum for this issue. Contingency fees and administrator percentage
shares are disclosed within their responses to RFP 1983.
Filing Limitations
The HealthSCOPE system can systematically apply the appropriate standard filing
limitation for submitting all claims. The standard filing limitation for submitting claims
for PEBP is twelve (12) months after date of service.
Unprocessed Claims Procedures
Unprocessed claims are logged on the HealthSCOPE system for verification of receipt.
HealthSCOPE has paper claims scanned and entered into their adjudication system within
twenty four (24) hours of receipt.
HealthSCOPE stated that this process and data entry will be conducted by individuals
within the continental United States. HealthSCOPE stated that they do utilize a company
that conducts this process outside the United Sates, however, has ensured that PEBP data
stays on shore.
HCA 05/16
Page 19
Reasonable/Customary and Maximum Allowances
HealthSCOPE is utilizing R&C allowances for non-network providers. HealthSCOPE is
utilizing R&C data for medical claims at the seventieth (70th) percentile. Out of Network
dental providers are paid using the same allowables as in-network dental providers,
subject to the appropriate geographic location rates.
R&C is applied utilizing the date of service and geographical location (zip code). R&C
data is updated four times per year by HealthSCOPE, last updated in April 2016.
HealthSCOPE does not have separate R&C schedules for Facilities versus Professional
services, however, HealthSCOPE uses a vendor that can apply reductions for Non PPO
facilities.
HealthSCOPE will pay medical claims at the appropriate network negotiated rates. Non
network providers and non- negotiated services will be paid at the lesser of the MDR rate
at the percentile chosen by the PEBP plan or the billed amount. Dental claims will be
paid at the lesser of the MDR rate at the percentile chosen by the PEBP plan or the billed
amount.
The HealthSCOPE system will pay the lower of charges or scheduled amount when
contracts allow.
The HealthSCOPE system utilizes modifiers to determine R&C for professional and
technical components for diagnostic, laboratory and radiological procedures.
Assistant surgical charges, when performed by MDs will be systematically calculated by
the HealthSCOPE system at 15% or 20% (appropriate rate) of the R&C amount (or the
network fee schedule) allowable for the surgeon’s procedure performed.
HealthSCOPE will pay all related charges of an inpatient stay at the network level if a
network hospital is utilized if the benefit plan dictates. This will be performed on a
manual basis by HealthSCOPE.
HealthSCOPE is utilizing a form of R&C for Non-PPO Durable Medical Equipment
(DME) claims when applicable.
In situations where the PEBP member has claims adjudicated under the PEBP Preferred
Provider Organization (PPO) Exception Rule (50 mile rule), HealthSCOPE will identify
these exceptions at the time of adjudication and pay within the Exception Rule per the
PEBP Master Plan Document.
HCA 05/16
Page 20
Membership Procedures
HealthSCOPE has the capabilities of electronic enrollment and re-enrollments.
HealthSCOPE will add or cancel employee information onto their system within twenty
four (24) hours.
Per HealthSCOPE, claims received for newborns can be paid and history tracked under
their own name.
The HealthSCOPE system analysts have inquiry capability to view eligibility files only.
They do not have the capability to make changes to eligibility information.
If an employee is terminated, the HealthSCOPE system will deny claims as not covered.
An explanation of benefits is generated every time a claim is received after this date.
HealthSCOPE will check for claims paid after this termination date.
Current historical eligibility information is stored on the HealthSCOPE system
indefinitely.
COBRA Administration
COBRA administration is being done by PEBP. If elected, determination for benefits
elected by individuals under COBRA administration rules can be done by HealthSCOPE.
The HealthSCOPE system can maintain an eligibility date that coincides with the
premium “paid to” COBRA date. If the system detects an exception to the date, it forces
human intervention. If the member is found to be terminated from COBRA, the claim is
denied. The HealthSCOPE COBRA system is integrated with the claims administration
system.
Provider Credentialing
Currently, providers are monitored by the PPO for credentialing. Claims received by
providers not in the PPO network are verified as legitimate by HealthSCOPE.
HealthSCOPE will check legitimacy of the provider through the internet and alternate
resources before payments are released.
HCA 05/16
Page 21
Coordination of Benefits
Coordination of Benefits (COB) information is obtained via enrollment applications and
claims displaying positive COB by HealthSCOPE.
HealthSCOPE states that all claims are investigated for COB information.
HealthSCOPE’s procedure for COB is to pursue then pay for all possible COB claims.
Claims are denied until requested information is received. If a claim form displays that a
spouse is employed, HealthSCOPE will send a COB questionnaire.
The HealthSCOPE system utilizes COB indicators, which will cause a warning edit to
alert the processor to the presence of other insurance.
The HealthSCOPE system utilizes separate COB indicators for different lines of business,
i.e. medical, dental, etc.
The HealthSCOPE system has electronic split indicators to assure the proper payment of
claims received out of sequence and multiple positive COB periods.
Per HealthSCOPE, COB processing is performed by all claim processors.
The HealthSCOPE system can process claims utilizing a COB Credit Reserve program
on a calendar year basis if required.
HealthSCOPE will utilize the primary carrier’s discount when the discount is greater than
the client’s if by Plan design.
HealthSCOPE policies are to recover overpayments of past paid claims when COB is
discovered after the fact.
Medicare
The HealthSCOPE system will alert the Processor when a member or dependent may be
eligible for Medicare benefits. If an individual is age sixty-five (65) or older and
Medicare may exist, active employment may be verified.
HealthSCOPE can present a report specific to active participants for verification to
eligibility files when requested.
Controlling Possible Fraudulent Claims and Security Access
HealthSCOPE claims analysts have a payment authority of $10,000.00. HealthSCOPE
Team Lead has an authority of $35,000.00 and the HealthSCOPE Claims Manager has an
authority of $75,000.00. HealthSCOPE directors review claim payments in excess of
$75,000.00.
HCA 05/16
Page 22
Security logs are created and monitored by HealthSCOPE. HealthSCOPE system utilizes
passwords, is monitored to restrict the use of certain system operations and can lockout
unauthorized users.
The HealthSCOPE system can track activity by individuals to identify who handled a
claim.
HealthSCOPE does currently offer website access to be used by clients for eligibility
purposes.
Quality Control and Internal Audit
HealthSCOPE has a total of 125+ claim analysts in their Little Rock location.
HealthSCOPE has 12 claims analysts dedicated to the PEBP account.
HealthSCOPE Claims Managers and Directors were found to be knowledgeable and
possess extensive training. Discussions and tests of their working knowledge of
adjudication processes and policies and procedures were positive. They were found to
possess the ability to identify and defeat many adjudication potential “problem areas”
defined with billing practices within the nation.
HealthSCOPE does not have internal audit personnel. They utilize an outside vendor that
conducts a review of no less than 2% of their claims.
HealthSCOPE has formal training programs, where policies and procedures are taught.
HealthSCOPE stated their training lasts four (4) weeks from the start. HealthSCOPE
offers consistent ongoing training and identifies needs of specific individual training. Any
needs are identified and supplied on an ongoing basis.
HealthSCOPE conducts audits on all processors. HealthSCOPE audits new analysts at
100% during their probationary period.
HealthSCOPE stated that experienced claim analysts will have the PEBP
performance guarantee levels met for claims per person per month audited.
Records for all analysts are kept on a database for performance reference by
HealthSCOPE.
HealthSCOPE has internal accuracy and production standards. HealthSCOPE’s internal
financial accuracy standard is 99.2% of paid claims and payment accuracy is 98%.
The production standard for HealthSCOPE experienced claims analysts is 150 - 175
medical/dental claims per day.
HCA 05/16
Page 23
Internet Capabilities
HealthSCOPE does have internet capabilities to further extend membership and
administrative service levels.
HealthSCOPE has internet sites provided for member information. These sites provide
claim information, network provider identification and contact data.
HealthSCOPE internet sites were user friendly and easy to access. HealthSCOPE’s site
was checked for security processes of data protection and was found to be protected by
member supplied passwords, etc.
HealthSCOPE has an internet site available for vendor information. These sites provide
claim and benefit information, network rates and contact data.
Communication between Utilization Review (UR) and Claims Department
HealthSCOPE can currently accept communication between the UR and the claims
department via electronic source. Information received regarding pre-certification, PCP
references and Case Management can be entered on the system when received.
Precertification penalties for non-compliance will be manually applied by HealthSCOPE.
HealthSCOPE will apply the proper cutbacks to UR authorized number of service days if
different than the number of billing days on a manual basis. HealthSCOPE verified that
they will apply authorized number of service days according to PEBP’s methodology.
HealthSCOPE analysts are trained to identify potential catastrophic cases and refer them
to a Case Management program.
The HealthSCOPE system has the ability to communicate special instructions or
negotiate arrangements/ discounts to the analysts through the notes.
PEBP’s policy allows for a three (3) Level Appeal process. HealthSCOPE stated that they
can apply this policy.
Claim Repricing Capabilities
HealthSCOPE is currently receiving network fee schedules and provider maintenance
data electronically for internal claims repricing. HealthSCOPE has data loaded into their
adjudication system within 24 hours of receiving.
HealthSCOPE currently is participating with multiple networks for repricing via the
Electronic Data Interface (EDI) methodology.
HCA 05/16
Page 24
Banking and Cash Flow
HealthSCOPE stated that they can accommodate PEBP’s requirement for payment
release frequency. HealthSCOPE stated that they could release payment checks the same
date of final adjudication if before 10:00 AM.
HealthSCOPE is utilizing bulk checks for provider payments.
Reporting Capabilities
In addition to the standard AD HOC reporting, HealthSCOPE has the capability to
develop and produce client-requested reports based on any information captured on the
system.
HealthSCOPE stated that no additional charge would be applied for any requested report
which is in the standard reporting.
General System
HealthSCOPE has been using the current system for twenty plus (20+) years. The current
system has undergone many updates since its inception.
HealthSCOPE has the controls in place for the application of source coding enabling
them to make client specific adjustments as necessary.
HealthSCOPE has written procedures in place for a formal Disaster Recovery program.
HealthSCOPE conducts daily system data backups, which are stored in a secure location
off site.
HealthSCOPE stated that they have not experienced any significant downtime.
Security
This audit reviewed building security, the handling and security of sensitive documents
and materials and the proper disposal of data for any potential data breaches. The audit
also reviewed internal processes and potential exposure to possible fraudulent activity.
The HealthSCOPE office located in Little Rock, Arkansas was found to be secure. All
external ingress and egress locations were secured and locked. Entrance was made
available to HealthSCOPE personnel by electronic pass keys. HCA entry beyond the
reception area required assistance from official personnel. The facility work areas are
monitored and recorded twenty four hours per day.
Sensitive data, specifically, member Personnel Health Information (PHI) of
HealthSCOPE’s clients was reviewed for security exposure practices. Any paper was
found to be in secured areas and/or file cabinets when not in use.
A review of the system server equipment for HealthSCOPE noted it was secured in a
separate area under locked environments with appropriate fire suppression protections.
Every attempt to access the adjudication system required appropriate security measures
such as passcodes, etc.
HCA 05/16
Page 25
HCA CLAIM AUDIT PROCEDURES
HCA selects a random sampling of claims from the client's current detailed claims
listings. The third party administrator is advised of the audit and requested to provide
either limited system access or paper reproduction of the entire file associated with each
random claim.
Each random claim and file is reviewed comparing eligibility and benefits to information
provided by the client. Third party administrator personnel are questioned regarding any
discrepancies. Entire files are reviewed to assure the client that deductibles, out-ofpockets benefit maximums and related claims are processed correctly. This allows HCA
to verify all details of the client's benefit plan.
Audit statistics involve only those claims chosen in the random selection. If a randomly
selected claim HealthSCOPE been recalculated or corrected prior to our audit, an error
was not charged for the original miscalculation. HCA will, at its opinion, comment on
any claim in the random claim history to illustrate situations it feels the client should be
aware of or specific areas requiring definition.
A payment error is charged when an error identified in claim processing results in an
under/ overpayment or a check being paid to the wrong party. Assignment errors are
considered payment errors since the plan could be liable for payment to the correct party.
In situations where there is disagreement between HCA and the third party administrator
as to what constitutes an error, both sides are presented in the report. Final determination
of error rests with the client.
HCA 05/16
Page 26
AUDIT RESULTS
Listed below are the errors or issues of discussion found by this audit while processing
the claims for PEBP.
Ref. No. 004
Medical
HSB claim no.
NOT charged in statistical calculation. Note to client for information only.
36223.50.51 chg 1654.00 allow 744.30 Multiple Surgical Guidelines applied
36226
502.00
270.60 Multiple Surgical Guidelines applied
76377.26
146.00
57.90
76937.26
62.00
12.99
Please supply the fee schedule rate for 36223 & 36226 without any
modifiers. SHO schedule SFS.100 but could not find the specific
services.
HSB response: Please see attached for rates.
HCA Note: 36223 contract rate w/o modifiers is $1332.59 and 36226
contract rate is $1475.41. Contract is lesser of 60% or 100% of SFS fee.
Claim should have been paid as:
36223.50.51 chg 1654.00 x 60% =
992.40
36226
902.00 x 60% = 544.20 x 50% = 270.60
76377.26
146.00 x RT =
57.90
76937.26
62.00 x RT =
12.99
TOTAL $1333.89
HSB Applied MSG to both services versus 60% off billed charges of
36223.50.51.
Ref. No. 087
Medical
HSB claim no.
Overpayment - $930.00
Audited claim CRNA - 00740 QX chg/allow/pd 1860.00 (non-PPO)
Claim xxxxxx also paid 1/26/16 for same DOS for anesthesiologist 00740 QK, P1 chg/allow/pd 1860.00 (non-PPO)
Why did both CRNA & anesthesiologist get the full amount?
Shouldn't allowable have been split between the two claims?
HSB response: Agree. Modifier overlooked on supervision claim in error.
Ref. No. 111
Medical
HSB claim no.
These labs were paid on 1/25/16 chg 240.10 allow 54.40
Claim adjusted on 4/5/16 to pay additional $0.05. Why the adjustment?
HSB response: New fee schedule received 1/21/16. QA reports created for
changes and claims adjusted.
HCA 05/16
Page 27
Ref. No. 116
Medical
HSB claim no.
Originally paid on 1/20/16 w/ $60.00 allowed
Adjusted on 2/18/16 w/$75.00 allowable due to SHO pricing correction
System reflects numerous adjustments caused by SHO pricing corrections.
Were there unusually high number of retro contract rate adjustments for
SHO in 2016?
Ref. No. 127
Medical
HSB claim no.
Claim orig pd as non-PPO on 9/11/15 (220.54 to ded)
Claim adj'd on 1/20/16 due to 50 mi radius rule. Pd $220.54
HSB response: No error. Claim processed OON. Patient lives in Caliente
not Dayton as shown on address of member. Claim reprocessed in net per
50 mile rule. No PT providers in Caliente on PEBP website.
Ref. No. 145
Medical
HSB claim no.
Audited claim is original
Claim xxxxxx adjustment for SHO fees on 4/5/16 claim paying 385.82
Overpayment now exists
When were updated SHO fees received?
Ref. No. 167
Medical
HSB claim no.
Claim for 88305, 88333, 88341, 88342
Claims xxxxxx & xxxxxx same DOS, same provider also for lab services
were denied as N/C under SHO contract.
Should audited claim have also been denied?
HSB response: No. Audited claim is correct. Bias claim xxxxxx is correct.
Bias claim xxxxxx - 88 codes should have been priced. Claim will be
adjusted.
Ref. No. 213
Medical
HSB claim no.
Claim originally paid on 2/5/16 at 51.97
Claim adjusted on 3/31/16 per SHO pricing correction
HCA 05/16
Page 28
Ref. No. 225
Outpatient Hospital
HSB claim no.
System reflects original claim had wrong PPO discount fee. Was this
because it was attempted w/SHO fees or something else?
HSB response: Analyst initially referred to SHO pricing in error. Processed
w/HTH pricing. original trans was reversed and not processed. Audited
claim is correct. No error.
Ref. No. 261
Medical
HSB claim no.
Member is Retiree w/Medicare B only
Claim not COB'd with Medicare. Shouldn't it have been?
Paid w/HTH repricing
HSB response: Yes. Claim should have been coordinated with Medicare.
Ref. No. 288
Medical
HSB claim no.
77056 chg 165.00 a/pd 80.45
99215
100.00
32.42
Claim being paid at 100% - ded/OOP not met. Claim has medical DX's.
Why was claim paid at 100% versus going to deductible?
HSB response: Office visit s/b split from mammogram. Mammogram is
1st plan year benefit.
Ref. No. 334
Medical
HSB claim no.
Underpayment - $1,960.09
Originally paid claim under xxxxxx on 12/14/15. Audited claim paid on
2/24/16.
38571.51.80 chg 1118.75 allow 212.56
55866.80.51
2320.00
440.80
3438.75
653.36 x 100% = $653.36 pd
EOB on this claim states asst surg fees are payable at 20% of the allowable
amt of the surgeon's fee.
Claim xxxxxx is surgeon's bill paid on 12/14/15
38571.51 chg 4475.00 allow 4251.25
55866
9280.00
8816.00
13,755.00
13,067.25 x 100% = $13,067.25 pd
Per contract = no reduction applied
Since both asst & surgeon's bills utilized the same fee schedule shouldn't
asst surgeon's bill be 2613.45 versus 653.36?
38571.51.80 4251.25 x 20% = 850.25
55866.80.51 8816.00 x 20% = 1763.20
HSB response: Yes. Agree claim will be adjusted.
HCA 05/16
Page 29
Ref. No. 334B
Medical
HSB claim no.
Claim xxxxxx CPT 00865 QK chg 1696.00 a/pd 1611.20
Claim xxxxxx
00865 QX
1568.00
1489.60
Why did CRNA & anesthesiologist both receive full allowable amounts?
Shouldn't fees have been split between the two?
HSB response: Provider bills w/cuts already taken for these services. We
only take 5% discount. No error.
HCA note: HCA would require additional documentation as each of the claims
appear to be for full charges for the anesthesia service.
Ref. No. 336
Medical
HSB claim no.
This patient had 3 tests on 1/29/16.
Claim xxxxxx is facility bill for all 3 tests all paid at 100%
Claim xxxxxx is for 2 of the test readings - both paid at 100%
Audited claim is for 1 of the test reading 76642.60 allow 42.34
All three tests had same DX. Shouldn't all billings be applied w/same
benefit? Should audited claim be paid at 100% versus 80%?
HSB response: No - ultrasound s/b at 80%. Audited claim is processed
correctly. All charges are for ultrasound.
Ref. No. 346
Medical
HSB claim no.
Services are for routine benefit.
Original claim xxxxxx applied 171.82 to ded on 11/30/15
Audited claim adjusted to routine benefit on 2/26/16
HSB response: Claim initially processed as illness. Post QA file reviewed
& reprocessed as wellness due to DX in history. No error.
Ref. No. 358
Outpatient Hospital
HSB claim no.
REV 510 chg 246.00
Medicaid paid $44.00 on this claim
Our adjudication reflects $246.00 applied to deductible. Shouldn't we have
applied our discount before applying to deductible?
HSB response: Medicaid reclamation claims are considered out of network.
No benefit to payout. All went to deductible. No error.
HCA 05/16
Page 30
Ref. No. 407
Outpatient Hospital
HSB claim no.
Claim paid as: 30520
chg 5838.70 a/pd 598.91
30140 LT
5838.70
598.91
30140 RT
5838.70
598.91
1796.72
Shouldn't claim have paid as:
30520
allow 898.36
pd 898.36
30140 LT, RT
898.36 x 150% = 1347.54 x 50% = 673.77
1572.13
Claim overpaid 224.59
HSB response: Agree. Bilateral reduction not applied. Claim will be
corrected.
Ref. No. 448
Medical
HSB claim no.
D7880 - occlusal orthotic device, by report
D7880 chg 1500.00 allow 1500.00 pd 1200.00 (in netwrk at 80%)
Since provider is non-PPO and has no Diversified Dental rate shouldn't
UCR have been applied? UCR = $909.85
HSB response: Yes dental UCR should have been applied.
Ref. No. 449
Medical
HSB claim no.
PT received services for both 45380 & 43239.51 from this provider
45380 was paid as routine & 43239.51 paid as a medical benefit
Audited claim (billed from same provider) is anesthesia for both services.
Shouldn't the anesthesia for the 45380 have been paid at 100% versus 80%?
HSB response: Audit claim is correct. Diagnostic colonoscopy. Txxxxxx
is incorrect and will be reconsidered.
Ref. No. 499
Medical
HSB claim no.
88305.TC chg 179.30 a 36.12 pd 28.90 on 2/25/16
Audited claim adjusted to pay additional 3.51 on 3/31/16
System reflects SHOSOUTHWEST was entered late. Appears SHO
contracts that are associated w/Medicare rates were updated late?
HCA 05/16
Page 31
Ref. No. 500
Medical
HSB claim no.
Original claim allowed 36.12 on 2/26/16 - applied to ded
Audited claim allowed 40.51 on 3/31/16 - applied to ded
Appears to be adjusted for SHO contract w/Medicare %?
Ref. No. 514
Inpatient Hospital
HSB claim no.
Claim originally paid at $6,639.68 on 1/14/16 per HTH pricing
Claim adjusted on 3/14/16 per HTH corrected repricing and new allowed
of $119,864.68
HSB response: Appears we have a display issue and will be opening ticket
with our system vendor for review. We will advise auditors to watch this
until we have a resolution.
HCA 05/16
Page 32
5.2.
5.
January 1, 2016 – March 31, 2016.
5.2. HealthSCOPE Benefits response to audit
report. (Mary Catherine Person, HSB)
27 Corporate Hill
Little Rock, AR 72205
May 4, 2016
Public Employees’ Benefits Program Board
State of Nevada
901 Stewart Street, Suite 1001
Carson City, NV 89701
Subject: Audit Results January 1, 2016 – March 31, 2016
Dear Public Employees’ Benefits Program (PEBP) Board:
HealthSCOPE Benefits appreciates the opportunity to respond to the audit performed by
Health Claim Auditors for the third quarter of Plan Year 2016. The audit included 500
claims with paid amounts totaling $249,299.85.
HealthSCOPE Benefits is very disappointed to have missed the financial accuracy
percentage by less than ½% for this audit period. We continue to review quality
improvement opportunities within our organization, as well as with our external
vendors. We take the audit process and our service to PEBP very seriously, and we are
constantly reviewing ways to enhance our performance.
Based on our review, we have implemented the following quality control measures:
Item (1)
HealthSCOPE Benefits will make additional programming enhancements for multiple
surgery claims, including assistant surgeon claims. We are also adding additional levels
of reviews of these claims prior to release. We continue to provide customized training
for the analysts on complex claims such as multiple surgeries, and we are evaluating
additional training methodologies..
Item (2)
HealthSCOPE Benefits will inquire about system modifications to automate the
application of rate reductions for anesthesia services when CRNA and anesthesiologists
Little Rock / Columbus / El Paso / Indianapolis / Los Angeles / Nashville / St. Louis
www.healthscopebenefits.com
bill the same session. In addition, we will conduct additional training on anesthesia
modifiers.
We continue to be pleased with the financial savings we are able to provide on the PEBP
account. We saved PEBP an additional $1,045,765 through non-network negotiations,
subrogation and transplant savings in the third quarter of Plan Year 2016.
We appreciate the quarterly audit process and the interaction between Health Claims
Auditors, PEBP, and HealthSCOPE Benefits as it provides for continuous improvement in
our service.
Thank you for the opportunity to respond to this report.
Sincerely,
Mary Catherine Person
President
Little Rock / Columbus / El Paso / Indianapolis / Los Angeles / Nashville / St. Louis
www.healthscopebenefits.com
5.3.
5.
January 1, 2016 – March 31, 2016.
5.3. Accept audit report findings and assess
penalties, if applicable, in accordance with the
performance guarantees included in the
contract pursuant to the recommendation of
Health Claim Auditors.

5. Health Claim Auditors, Inc. quarterly audit of HealthSCOPE

Transcription

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