Based upon the unique nature of healthcare claims auditing, we engaged the services of a specialized commercial auditor, J. Graham Inc., Healthcare Claims Audits (JGI), to conduct an audit of the County’s contracted healthcare services administrator, Humana Health Plan, Inc. (Humana), for claims incurred from January 1, 2015 through December 31, 2016. Over the two-year review period, the County’s plan served approximately 10,400 members (active County employees, plus retirees, COBRA, and WorkForce One, and their dependents), with an approximate total of $63,000,000 in claims paid.
The focus of JGI’s review was to ensure the accuracy of Humana’s claims adjudication services, based upon factors including, but not limited to, verification of amounts charged, application of deductibles, co-pays, coinsurance, coordination of benefits, and plan documents. A copy of JGI’s March 13, 2018 report, inclusive of Humana’s responses, is enclosed herein.
In summary, JGI reports that:
- No large systemic errors or high dollar value individual claim errors were identified.
- Overall recovery rate is low, with the total of all recovery items at $114,987.
The report also includes additional informational findings that may be of value to the County in considering its ongoing healthcare plan design.
We concur with JGI’s assessment of the claim adjudication errors, including all disputed and out-of-sample error applications. We understand County Administration will be working with Humana and JGI to pursue recovery of the questioned costs. |