>> okay, so financial errors are going to look at the financial impact of the audit. and the payment errors are the frequency of errors. so the financial errors are going to look only at the financial aspect >> can you try one more. >> the financial accuratecy, one penny does not have as much impact as one million dollars it is looking at the accuracy of dollars paid out verses payment accuracy is looking at the frequency of payment errors in the sample. so, you could have a one penny error, a $10 error, and a $5, error and they are equal weight with the payment accuracy. >> could i give it back to you to make sure that i understand it. >> financial is the value of the error?

>> of the dollar amount, right, exactly. >> and payment is just that an error was made. >> and any kind of payment error in the sample and so anything that is origin, it could be of any dollar size, and counts as an error. >> and over all, it is all kinds of errors, financial or payment or non-payment error and we are looking at over member experience and you can have a situation where the claim is miskeyed for a date of service. and that particular claim may pay the right amount, but it could lead to a financial error at a later date because it could cause the duplicate claims to be paid and such, and so over all accuracy, we are looking at the frequency of any type of error in our sample. >> thank you. >> commissioner shlain? >> in your separate, and in your, and yeah, in the separate, so you did 220 general audits and you kind of

come down into the ten, high dollar ones and then ten and the instage renal ones. and so i guess, i mean, end stage renal is expensive and so, when you do ten high dollar and ten, those to me are the both the same thing and i am just wondering why. but that is not, that is just a question part a and part b, is. and you know, when you look at a pyramid, you know, the expensive things at the top of the pyramid, but they represent a large portion, and it is a small number of things that represent a portion at the bottom. but they live at the top. when you get to like the very expensive things, but when you get to the bottom, you have a lot of little things that actually add up to more than the top of the pyramid and i know that you did a random sampling and i wonder if you would do a sampling of the ten, not the ten, but, the conditions that cost very little, but represent a huge dollar amount as a separate slice of an audit as opposed to the ones just at the top of the

pyramid. does that make sense? so you audit everything, equally and you find the things but the special audits at the top. there are no special at the bottom, meaning that these 50 dollar things that happen $5 million times and i wonder if we wouldn't do a special audit of the high frequency things and the low dollar things, because they add up to be more than the other ones. >> okay. to address the question, regarding the ten high dollar claims and the instage renal claims and those come by the 2012 audit. and we determined some errors within esrd, as well as some high dollars, so we specifically honed in on those claims, to determine for a special targeted audit. for our general audit, our 220 claims, they are stratified claims and so we are looking at

a full aspect. and we have a zero pay and so the claims that payed zero and went to the patient's deductible or denied the claims, paid a penny to 500, and so you are at a 500 to a 2500, or to $5,000, or $5,000 and above and so we look at a large, range of claims, in different conditions, as well. and the two specific conditions, in the targeted audit, again, came from our 2012 audit. >> right. >> but just to put a fine point on this and i think that you understand it, but i want to put a fine point on it, is if there are claims that are a dollar to $500, is that the low strata there? which one of those are the most frequent? and so of the 0 to 500 dollar claims are 50 percent of those 50 dollar claims for a specific thing? we should target those, because if, you know, just take a random sampling of those, you know, i am sure that most of the claims are 0 to $500, and

that is the bulk of claims and so within those, there is probably some codes, diagnosis codes that represent the massive majority of those, and so i want to focus in on it, so if everyone is up by $5 and it happens 55,000 times and we don't audit that because it is too small and we don't appreciate the frequency that leads to a big dollar amount. >> so, it is we randomly select within the each strata, bucket but we see a lot of the most frequent claims because there is a high volume. if you look at the high volume of claims and normally see the physical therapy and the office claims in the universe, those are going to end up in the sample. through that random process. >> so you have your dollar strata and we have such a large portion of our selection, that are in that zero pay or the one penny to the $500 where the

bulk of the universe is. so... >> yes. >> and the claim is up one. >> and yes, claim, wise. >> and i think that we can in next year's audit, we can add that. >> yeah, i think that we can actually look at that from a statistical standpoint off line. >> okay. >> thank you. >> thank you. >> in addition to our 220 claim audits, we have we also classify out of sample error, and it will be an error that was related to our sample claim. and so, the best example would be anxillary charge if our was a facility charge and any of the charges that may impact that charge will also be audited and if an error was found on those, that would be an out of sample error. >> and we have the results of

the 2014, audit, as well as the 2012 audit so that we could compare to see the improvements by uhc and we also on the right-hand side, compare the results to the objective for the minimum level. >> and financial accuratecy and over all accuracy, did not prove in the 2014 audit. and the frequency of errors increased. and however, the dollar amount of the errors decreased by almost 10,000. >> in addition of the targeted claims of the 20 target td claims, 6 of the errors were due to manual ajudication and we did notify any systemic errors of the targeted claims and the next few slides we will

be comparing the audit results to the passed 20 audits and completed by aon. and these are blind audits and they are not just of the uhc and they are across the board of any carrier that we have audited 220 claims this rements the satisfaction and the shaded red hashed line, represents where uhc fell in this year's audit. and we can see for the financial accuracy, uhc, while improved from last or from 2012, still was below our minimum satisfaction level.

>> is that big, or is that little? and i don't know if someone falls in at 78 percent and that gives me a framework of how to understand this. >> well, when, this gives you an idea of the 20 most recent, and the lowest one was 97.3 percent and this is obviously changing on a weekly basis because we do so many audits but it is definitely lower than we would like to see. and but, we don't think that the ship is sinking, we think that they can definitely get it up to a higher level. it is just shy of one percent but you can see in this range,

generally, we have all the way up to 100, and it was rare, to see below like a 97.4 and it does happen, and we have some that are significantly below, and it is not a every day thing. >> do you guys ever watch over payments and things, that actually with the benefit. >> and yeah, over payments is a big, and under payments and certainly, and we see quite a few over payments when we do our audits. we will compare with over all accuracy. and again, things shading where uhc did much better with over all accuracy, from improving doing better than eight of the past, since the audits that we have completed. the payment accuracy, and this

is one, where uhc barely missed our standard at 9748 uhc, our standard is 9950. so, because of the frequency, of errors, just barely missed or satisfaction level. >> and here is where we get into the over payment and the under payments for the errors. and for insample we have a total of 12 errors and 9 in-sample errors and three out of sample errors. of the errors identified, four of the errors were manually adjudicated errors related to medicare coordination of benefit and two were related to charges that were incorrectly denied. and uhc did agree to all four of these errors and reprocessed the charges, prior to our audit and so uhc did know about these error and did correct them prior to the audit. >> we also have two errors, and

regarding two out of sample errors. and regarding anxillary services for colonose co-py and they disagreed with it and uhc did recently provide additional information to their disagreement and we are in the process of rereviewing each of the errors that uhc did disagree to. >> and at the bottom of the page, we also have over payments, and the total over payments and the under payments for our in-sample claims. >> may i ask a question on this slide? so you said on the metrics and the nine in-sample claim errors, six were system errors they have corrected them? >> uhc is in the process of correcting, i believe that there are two left to corrects, where impact reports were being

run. >> two of the errors of that were, identified were claims that were denied requesting other insurance information from medicare primary participants and uhc acknowledged that system error at the time of the response by uhc it had not been corrected. >> so it says to i guess that we will hear from uhc at some point and so as far as we are aware that error continues today. >> as far as we know that. >> okay. >> and if the over payments are 2.749, can you give us any estimate of the total impact if this is... and could you only, you took 220 out of whatever, the universe of claims are. >> again, we are waiting for the reporting from uhc. regarding the impact of the claims. however claims it did impact.

>> okay but there sno way to give usen estimate. >> you did a sample and if you were to apply the sample to the over all universe? >> right. so, we do not extrapolate out to say that because you had this number of errors in the sample, that means that it is exactly the same in the universe, but we do work one on one with uhc, to quantify the over all financial impacts, to the universe of those systemic issues that we identified. and they run reports, and provide us with information to determine what is the over all impact. and are the over payments or under payments? and so that is just... >> why don't you apply it? >> we don't believe in extrapolating out to say, because we had a $5 error here that means that it is $5 million dollar error in the universe. >> why not? >> so it is just our they have

done an analysis and determined that is not the process that we utilize and but we do work one on one... we do work one on one with the administrators to determine, the over all impact. and in the universe. so it does not mean that we stop at the sample, we work closely with them to determine, how many claims are affected. >> other questions, from commissioners? >> so, you know, sample of the claims, what percentage of that in the total universe? >> it is, we use an error of driven formula, to select our sample. and it is not a, we are not taking a percentage of over all universe of claims. >> understood, but what percentage of that 220, is two percent of the total universe, five percent? 20 in >> no, it is not. it is much, it is a much smaller amount than that. so... >> so. >> it would be.

>> one percent? >> less than one percent over all. >> okay. >> in the universe. within a whole year's worth of claims. >> okay. >> you are not talking about extrapolation, but if is one percent, and within the 220, if you found, five percent error rate, likelihood that out of that 99 percent, you might have also... >> so, our results are weighted based on the over all universe of claims. >> understood. >> and so, that the statistical accuracy is weighted based on the over all universe of claims. and so it is not a, like a pure random calculation based on the 220 claims. we have a formula that we use that so many claims in the universe for each bucket and your accuracy is weighted to the universe, but we don't extrapolate dollars, we do not

say that because we had 2,792 in the sample, because, we only ad uted less than one percent of the claims that is multiplied out.

and you need to be doing a better job, in over all claims payments. and that will be the advocacy that will represent here on the board and i will recognize that it will not necessarily give you great comfort as a stastician but we need to translate to a policy understanding as we interact with the vendor. >> understood. >> okay. >> so, 100 percent behind you, thank you very much. >> and what i would suggest, because what i hear you saying is, because you have actually asked uhc to run what is the

effective this, and the next time that you do this, don't present the audit without those findings, because you will go through this again. >> because really we are sitting here saying and with the commissioner asked the first time, how big is this? and right now, you can't tell us. >> exactly. >> you need to have the impact report. >> right. >> and that will be helpful. >> yeah, and i know that the tendency will be to drowned us and you will have all of these qualifying statements that you try to provide something of a layman's summary. if you can. and then i know that it is hard, statistically sometimes, right? >> okay, thank you. >> thank you. >> so, the claims audit, we asked that information on the targeted claims, and the ten high dollar and the ten srd claims. so we find the two in-sample

error and four out of sample errors on the targeted claims and now it should be noted that the targeted claims are not included in the statistical results of the audit, they are presented separately and the largest of the errors which uhd did agree to and under payment, in the amount of 208,080, what happened was that the claim that was manually denied by a process or in correctly. and now it should be noted that uhc did correct this error prior to our audit, and feedback was provided to the processor, and regarding the filing the correct process and the guidelines. >> could i just jump in, i am a freak for details, do you know exactly what process they did not follow to make a $200,000 error? is there like i clicked the wrong button?

or i mean, what exactly happened? >> so what the error resulted around and we have an in-patient stay where the member had precertificated for that stay. the processor did not read the notes within the file and denied the claim, requesting for medical records, where uhc had already approved the stay, the processor did not follow the correct guidelines in looking through the file to determine that the claim had already been reviewed. so that is where the under payment came from. >> and was that person fired? >> okay. >> there is also, one additional under payment. and at the bottom, and of the notes and for 86,481.25 dollars, and when uhc did respond to our report, uhc did provide additional information regarding this error and that there will be removed from the

list of errors. and uhc did provide the justification for the denial of this claim. >> so in addition to conducting a statistical audit as well as a two targeted audits, another come poeb component that we do is an administrational assessment. and it is a way to get a better understanding of the over all level of the claimed customer service that your members are receiving. and we go in and we essentially kick the tires, and insure that the services sound and look for ways for the administrator to provide and enhance level of service going forward. and where they fall short, as well as best practices, that they may be needing. so, we reviewed uhc, and four

key areas facility and organization and staffing, and claims and administration, and customer service, as well as audit programs. and we provided them with an analysis and determined that they were in a satisfaction range, with two bs and two cs. and so, certainly there are areas for improvement, but, they are in the middle of the pack and it is like the bell curve the way that assign a grade and most are in the middle and a couple at the top and a couple at the bottom and uhc tends to generally follow in the middle range. and a couple of key contributers, to the fee, and the facility environment and staffing, very high level of turnover, attrition, statistics being reported for the claims and the customer service staff, much higher than we typically

see and so you are going to experience the turnover and they have to bring in the new people and provide them with training. and the tenure from a claim's perspective, the claim process ors have a satisfaction level of tenure, but we felt like the customer service or health advisor, tenure, was light, quite a large percentage of your assigned representatives, have less than two years of experience, from a staffing level, perspective, the number of staff assigned, it seems to be appropriate, because they are generally meeting your claim turn around time and your telephone responsiveness, objectives and, from a looking at the over all service facility, we think that the chico service center is quite stable. and not a lot of growth, basically extremely modest at

one percent decline. and on the next category, the claim administration, very, very high level of claims, on your calendar, are received electronically and so, with less coming in by paper, there is less human error of keying of the claims, we could not obtain the statistics, to form a statistics, and from those vendors, and so, that is, we hope that uhc reconsiders the position there going forward. so that there is full discloser on the inventory control

performance and, we looked at auto adjudication rates and what percentage are automatically processed by the system rather than requiring the review manually by a processor and a high level of rate there. positive things here, is... >> could you just give us the highlights. >> sure. >> a couple of other highlights, just over all, handling over the payment, and recovery, coordination of the benefits and activities and are in line with what we typically see in the industry, and so a solid b in this category. and the customer service, and your hours of operation in line with what we typically see for other clients, participants, and we wish that they offered

secure messaging to the members and that is where they fall down a little bit and we looked at the first call resolution and performance and the struggle to resolve the calls on the first contact and a couple of other highlights, resolving open issues and right now there are no reports to show, how quickly uhc is able to close open issues, on your account, and so, that contributed to the fee. s the audit programs, a solid b, the level of review done by the management is in line with what we see when they are looking at the claim quality of the individual process or. and the high dollar audits using a 10,000 dollar threshold

for a second level of set of eyes review and that is in line with what we see in the industry, generally they are meeting your contract objectives for accuracy and turn around time and only the area of improvement, i think is maybe to increase level of the call audits but still, there is still a very solid b. and so, if we were to blend this score, over all, i would say, that they are closer to a b than a c. >> uhc will be providing a corrective action plan? >> correct, we are working with uhc, they did provide additional information, for some of the auditors and so we will review, each of the errors that uhc disagrees with, and we will ask uhc to provide an updated action plan, based upon the newer ors. >> i would like to asked the other commissioners, this kind of a grade we would like them

to present to us not just a written response to the staff. >> i agree. >> why they don't offer it, what customer service on earth does not have access to secure messaging? >> and they own a company, optum that does way more than secure messaging, and that i used to advice for, and so, the capabilities are there, just not turned on. >> the call back capability reporting, what exactly is this. >> this is a wish list item, and we would love for the administrators to have it. if a member calls in and the issue is not resolved right then and there is say that it is a claim that needs to be