there was a huge difference between kaiser and blue shield and kaiser said we have a different prescribing pattern of blue shield so will you go back, kaiser could have done the analysis themselves. they wanted it to be n.d.p. -- independent and they went back and did it independently. i will admit it was my understanding that the data itself, because i remember we talked about kaiser having 16 diagnosis because they keep more data and blue shield having three, that we had to say this is how many diagnosis we are going to look at for each claim but what we are looking at is the actual what the diagnosis was when they were admitted to the hospital. we weren't looking at ambulatory data. when i got admitted to the hospital last

year, i had a cancer diagnosis, diabetes diagnosis and rb diagnosis. those are the three diagnosis that were made at the hospital. your point commissioner is we are not looking at the people who are well managed are and i'm saying, i'm repeating your point because we will revisit this issue with red -- request from the vendors that having a low risk score that you didn't get sent to the hospital. >> that was well said. >> that is precisely my point about context and application in this particular case and it needs to be a part of this if we are going to have this discussion annually, then we

need to frame kind of why we are doing it, what it is and what the result is because that doesn't communicate year to year. we'll walk out here today and i can guarantee you no member of the public or most of this commission will remember exactly what we said on this topic. so we need to talk about points of continuity. i'm not talking about the result, i'm talking about the presentation in this particular case. >> okay. i'm dismissed. >> you are not dismissed. is there any further comment? >> any public comment on this item? >> we managed to confuse you. i'm with you. it's a christmas party for you and me. >> and there is a white paper that goes along with this.

thank you. next item. city clerk: item 11. uhc city plan audit follow up, aon hewitt. >> i'm going to ask that you move forward with your presentation. >> today's presentation was closing the 2014 medical plan audit in addition there were many questions asked during our last presentation regarding the methodology and

extrapolation. page 2. just to give a recap plan evaluation method ology. we looked at 220 claims for the entire year of 2013. the sample size there was a question about statistic relevancy. sample size 95 percent plus or minus 7.5 percent. we'll get into presentation on how we broke down the claims for strata and the amount of claims we looked at. there was a question in our last presentation about the high dollar rate. we looked at 10 high dollar claims and the stage reasonable -- renal disease

claims and our sample of 10 claims will not statistically relevant, did you tell provide a highlight and overview of how the uhc process those types of claims. an example, one of the errors we did identify on the audit was from our targeted claims. just from those 10 claims we looked at for each set, we were able to determine a picture of how uhc processes each of those types of claims. plan methodology, we have the payment errors and non-payment errors. when we get to the actual audit we have some items that agree or disagree or lack of consensus. with

uhc, if they have identified and corrected an error prior to our audit they do not consider that an error. that is one area where we differ within our scores. question on the methodology why we looked at the 220 claims. the sampling is a stratified random sampling methodology that does not take into account the size of the group, nor the population covered, no matter what timeframe we looked at. we would expects similar results. >> it's an error rate driven formula. the point is because it's an error rate driven formula, there is this size

of the overall population would not really matter. i just wanted to make that clear. >> you need to identify yourself. >> this is ann fulton with hewitt. >> claim audit process. this is a review again from what we reviewed during our audit process. there were questions in our out of sample claim. this is an example, an emergency room claim if we identified an error in subsequent x-ray claim, that would be considered out of sample. >> we had a question on why we stratify our sample, the size really impacts the claim

process egg -- processes utilized. the large claims have more control in place. you have administrators doing predisbursement audit and doing claim reveals and medical necessity reviews. the lower dollars are automated with the processes. we find that the side of the claim there are different characteristics as a result of the size of the claim. so we felt like we needed to break out and look at payment thresholds. that is why we needed to stratify the different claims in processing and we stratify the position without the sample because we are trying to keep it affordable obviously this audit and this is a good way, we feel like with our

confidence level, the results are valid and we also, we mentioned that we break it into five strata categories. we have the ze -- zero pays, those can be any size. they are not going to be overpays because they are zero pays. we have seen $500,000 pay amounts and when we look other categories for strata level four, we find the errors and claims with the small payments are likely less variable than the errors with the claims with the large payments. ? in our sample size with the entire population as accurately as possible with

the 220 sample size. the next page is is strap laegs. xrapgs. we extrapolate to get the sample size to the population we are extrapolating . the error estimates including overpayments and under payments and with the overall universe thick net each other out. in order to determine the true overpaid amount in the universe actual claims have to be identified and we work with administrators like uhc to run the impact reports. in a few minutes we'll have uhc

discuss the impact on the specific errors we identified. we wanted to provide you with our claim sample statistics. we have the total submitted with our sample as well as total paid for strata and the last column is a percent of charges paid within each strata. then you have the overall population of claims. so for the period january 1st-december 3rd # 1, these are claims and processed so we wouldn't have claims prior to 2013. you see within the entire universe a little over 76,000 claims processed by uhc

>> can i ask a question. on the zero payment strata. if you look at the last column which you title percent of claims, that's not actually percent -- >> percent of charges paid. percent of claims charges paid. >> so my question is is if you actually, i'm just trying to look at because what it does to me is under value the zeroes that they are not a part of anything. if you paid 0, it's consistently 0. where the truth is maybe we were supposed to pay on some of those. it doesn't show there is an actual risk to us. am i making sense because it looks

like $50 charged. >> so with our error rate it's financially accuracy is the absolute value of those errors, so under payments are going to be an issue for the administrator and their accuracy score will reflect the under payments in this. so it's not, it's not under, i guess i don't understand your question, we are not under valuing the impact of them. we don't net anything out so an under payment of $20 has just as much of a hit on the administrator as the overpayment of $20. >> right, to give it back to you, as we talked about last time you are coming back and telling us again you give us no estimate to that positive

or negative. because of the risk is for us, it does matter. we are under reporting how much we actually owe. what you are coming back and telling us is you are not extrapolating out. >> we are extrapolating the error rate. 98.3 percent is the performance from this audit so we would expect from the universal claim that 1.68 percent of the claims are miss paid from a foreman -- financial perspective. >> right, we have no -- >> from dollars what we have to view is work with uhc and run the impact reports and go through that process to determine the true errors. we can estimate it but it tends to be very far off of reality so that's why we are looking

at actual claims with uhc, running the impact reports true, once we know the root cause of the error they can run the reports to identify all the claims of the universe. >> right which you told us they are going to present after you. >> so audit finding once the last presentation we had three errors removed based upon additional information provided by uhc. we had an out of sample error removed for $9. an overpayment of $7600 removed and $86,000 removed. they are not included in our statistical results. the results are the final results which are shown on slide nine. we have the

2014 results and as well as the 2012 to compare to see the differences. on page 10, key audit findings. we have summed up the sample. the errors. the first column on the claim sample. the bottom is on the targeted two in sample errors and two out of sample errors and key note agree to 7 of the 11 errors identified in the 2012 claim audit in the four audit > i

would like you to requote the rates. >> that would be a dollar point. >> there were lower scores on overall accuracy and payment accuracy? >> yes. >> rené marcus united health care. >> can you identify your position? >> i'm the senior external audit team. so i wanted to highlight the errors

identified and agreed to during the audits conducts by ann hut. hewitt. from the statistical audit there were 11 errors identified by ann hewitt. united care agreed to seven. overpayment were 1700, those have all been corrected and reimbursed correctly. the total target. hewitt cited four errors, united health care agreed to two of them and one was realm bursed and the other one was recovered.

united health care also breaks down the two errors in terms of error source. so we want to know what caused the errors, how we can prevent them, etc. so, for systemic repeatable errors united care produce impact reports for the entire population to get an estimate of additional claims that are miss paid. so as a result of the statistical audit we did have two systemic errors, actually three systemic errors, two of the systemic errors involved the same cause and the systemic error has been corrected. we ran an impact report across

the population and found they were under paying on the same issue. $3069 and they have been reimbursed. that systemic issue had to do with benefits and that's been corrected. the impact report for that issue and we identified both claims in the population. $2538, they have an been reimbursed correctly. $5061 for adjustment and recovery and are pending reimbursement. >> is any of this provided to us in writing? >> >> yes. it's included in ann

hewitt's report. >> it's not in the analysis what you told us in terms of how many claims and the dollar values. is that included somewhere in >> it is. it's included in the last column in the tables pages 11-12 estimated group financial impact. >> it's the column. and the na is because you have determined it's annoy a systemic error. >> that's right. it's an error that we did not agree with or an error due to process or which was not systemic repeatable. >> i just want to make clear if you disagreed you did not

do a financial analysis even though our auditors continue to disagree with you. you just said is we don't agree and we are not going to show you the numbers. >> correct. if we did not agree, we did not run a corrective analysis. >> we appreciate your opinion on the matter and would like to see the numbers on this. for future we would like to see them, totally we understand reasonable minds candice agree, but if reasonable minds can -- disagree, we should have that information so we can assess whether we need to go further and revolve the difference. so for the non-systemic errors you make no extrapolating. >> so basically if an error is agreed due to adjudication or

keying error it's review and feedback with a responsible process or and keyer and or the dedicated team. to our own internal control we monitor manual adjudication errors to look for trends. >> my suggestion is and this is to the staff when audits are done that they do a corrective action plan in writing so they actually write down what they did so we can see if these errors are in fact occurring year to year. my other question is is are there performance guaranty because i will note the error rate is unsatisfactory 2 out of 3. >> as part of the external process does write a report in response to ann hewitt and it

goes step by step each error identified by an hewitt so we have that information available if you would like to look at it. >> i think it would be great to include it in the packet. >> i believe we got it last month and i believe the board got it last month. you had a report as well as the deck last month. >> an hewitt came and presented preliminary findings and they wrote a corrective action based on preliminary findings but the corrective action was just from a preliminary. it would logically flow at least for me but i won't be here but you can do it at a different way that it will come at the end so people like me don't say, where is that? >> any other questions or comments? >> you would need to hold

that in the financial report. >> i understand what hut has what they consider for accuracy, financial accuracy and payment accuracy. what are your standards? >> united health care standards? >> >> in these three categories? >> sure based on paid dollars is 99 percent. payment accuracy is is 97 percent and overall accuracy is 95 percent. >> let me ask, i'm sure you won't have this at the tip of your tongue, with that type of accuracy level what's the consequence to united health care with those kinds of targets in place. does that impact you in anyway if you are paying claims or claims are not accurate to the level that you just described, does

it have an impact in your operation? >> if the group has a performance guaranty united health care reports a monthly statistical audit report on the results and if they fall below performance guaranty then there are penalties on unit health care. >> you said there are standard levels for accuracy, when the performance is not met what do you do? >> >> we take these standards very carefully. we have quality management and we do have intense training for our claims processors and we constantly are updating our training documents to ensure

that the most current information and it does change a lot is made available. processers go through an intense training class when they come to united health care and those trainings continue tullius -- throughout the year and web basing applications as well as classroom training if needed side by side process or training and we have an -- array of different quality controls to make sure they are processing correctly. one of our enhancements is smart audit rule which takes scenarios that are known to be problematic and after the claim is is processed but before the payment is released, the claim is actually held in a cue where

another individual has to take a look at that claim and double check to make sure it was paid appropriately. >> all right, thank you. what i would ask from an hewitt when you have satisfactory, that's based on what. how did you pick this point to say this is excellent performance, this is good performance and this is satisfactory. >> this is an fulton with an hewitt. we do hundreds of audits a year. we constantly evaluate what are reasonable objectives based on what we have seen in the industry. we have had these objectives since 2008, prior though that we had financial for payment and 95 for overall accuracy. in 2008 we determined the bar keeps on raising, the administrators are doing better and better and what is

acceptable and to us based on hundreds of audits a year across all major administrators even third party administrators, we have determined that 99.3 financial is acceptable and 95 acceptable for payments and the good and excellent looking at what are we seeing in the industry like the bell curve, there is not going to be many but we've had 100 percent accuracy with the administrators. it's from years and years of auditing experience, we felt like these are appropriate, and many of the administrators achieve and exceed these objectives. they are very reasonable objectives so we feel like we should hold all the administrators to these objectives and

consistently across all of our audits. we don't change the objectives from one at straer -- administrator to another. >> thank you, we just wanted to get that into record, there is a variation and we don't know the total impact and there needs to be some articulation and if we go forward to talk about performance guarantees with the administrator, this should be noted. >> any other comments by commissioners? >> seeing none, is there any public comment on this item? >> yes? >> >> to close out the audit we had final recommendations to go over on page 13. these are going over the last meeting. >> great and we have received them if they have not changed. is that