05/27/2003 Audit c®Stt
AUDIT REPORT OF
MONROE COUNTY
HEALTH BENEFIT PROGRAM
May 27, 2003
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Prepared by:
Internal Audit Department
Clerk of the Circuit Court
Danny L. Kolhage, Clerk
Monroe County, Florida
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CLERK OF THE CIRCUIT COURT
MONROE COUNTY BRANCH OFFICE
BRANCH OFFICE PLANTATION KEY
MARATHON SUB COURTHOUSE MONROE COUNTY COURTHOUSE GOVERNMENT CENTER
3117 OVERSEAS HIGHWAY 500 WHITEHEAD STREET,SUITE 101 88820 OVERSEAS HIGHWAY
MARATHON,FLORIDA 33050 KEY WEST,FLORIDA 33040 PLANTATION KEY,FLORIDA 33070
TEL.(305)289-6027 TEL.(305)292-3550 TEL.(305)852 7145
-, FAX(305)289-1745 FAX(305)295-3663 FAX(305)852-7146
May 27, 2003
The Honorable Danny L. Kolhage
Clerk of the Circuit Court
Re: Audit of the Monroe County Health Benefit Program
ji
Dear Mr. Kolhage:
The Clerk's Internal Audit Department has completed the audit of the Monroe County Health
Benefit Program. The purpose of the audit was to assess compliance with the applicable chapters
of the Florida Statutes, and the Monroe County Board of County Commissioners' policies,
procedures, resolutions, ordinances and agreements. We also evaluated the extent to which
Acordia National (third party administrator) and Keys Physician-Hospital Alliance (KPHA)
implemented procedures to administer the Health Plan and to evaluate the effectiveness of County
Management's systems employed to monitor the Contractor's performance.
We would like to thank the Division Director of Administrative Services and her staff for their
cooperation while conducting the audit. By its nature, this report focuses on exceptions,
weaknesses, and problems. This should not be understood to mean there are not also various
strengths and accomplishments.
Our audit revealed that although the County has contracts with private business organizations to
administer the health program, strong financial and internal controls are needed in the contracts.
Due to the complexity of the constantly changing healthcare industry and the large costs involved,
constant oversight and monitoring are required by Monroe County Management.
i_ The audit was completed with the assistance of Patricia Sutton, Internal Auditor.
The accompanying audit report is provided for your information. Additional copies of the report
will be provided upon your request.
Sincerely,
Sandra L. Mathena, CIA, CFE, CPA
Director of Internal Audit
'l Cc: Board of County Commissioners (5)
James Roberts, County Administrator
Sheila Barker, Division Director of Administrative Services
Sandee Carlile, Clerk's Finance Director
Marva Green, External Auditor
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AUDIT REPORT OF MONROE COUNTY
HEALTH BENEFIT PROGRAM
TABLE OF CONTENTS
Page
I. SCOPE AND OBJECTIVES 1
II. METHODOLOGY 1-2
III. BACKGROUND 3-6
IV. CONCLUSIONS 7-9
V. AUDIT FINDINGS:
A. Third Party Administrator's Calculation of Payments to Providers
1. Prompt Pay Discounts - In Network KPHA 10-12
2. 1997 Medicode Fee Schedule Used for Comparison of Reasonable
Customary Charges 13-14
3. KPHA Providers Added to Acordia's System Incorrectly 15
4. Claims Paid For Two Ineligible Providers 16
5. Providers in Both KPHA and Dimension Networks Paid Using Smaller
Discount 17
6. Miscellaneous Errors 18
B. Monitoring
1. Monitoring of Claims Not Implemented 19
2. Written Confirmation of Changes 20
C. Provider Claims Paid as Out of Network Claims
1. KPHA Provider Claims Paid as Out of Network Claims 21
2. Dimension Provider Claims Paid as Referrals 22
D. Certain Dimension Claims are Paid Over Usual and Customary 23-24
E. Maintaining Eligible Member Records
1. County Entities and Departments Not Reporting Employee Changes Timely 25
2. Terminated Employees and Dependents Listed as Active on Acordia
Employee/Dependent File Listing 26
F. Agreements
1. Right to Audit Clause in Employer-Provider Network and Utilization
Review and Case Management Services Agreement 27
2. Usual and Customary Reimbursed at 90%Medicode 28
G. Utilization Review
1. Independence 29
2. Documentation of Utilization Review Notes on Acordia's System 30
3. Outside Audits For Large Hospitalizations 31
H. Employee Benefit Plan Document Dated October 1, 1996 32
I. Payment Method Employed For Surgical Procedures 33
J. Chiropractic and Massage Therapy Visits 34
VI. EXHIBITS
A. Administrative Service Agreement
B. Monroe County Board of Commissions Cost Per Employee Comparison
C. Employer-Provider Network and Utilization Review and Case Management
Services Agreement
D. KPHA Letter Defining Calculation of Prompt Pay Discount
E. Acordia Explanation of Benefits
F. KPHA Network Payments Memo
G. Acordia's Preliminary 2003 Schedules of Overpayments
H. Claim File Audit Checklist
I. Exclusion for Out-of Network Services
J. Letter From Lower Keys Medical Center On KPHA's Contractual Obligation To
Monroe County
K. Letter From Executive Director on Return of Organization Exempt From Income Tax
VII. AUDITEE RESPONSES
AUDIT REPORT OF MONROE COUNTY
HEALTH BENEFIT PROGRAM
I. OBJECTIVES AND SCOPE
At the request of the Monroe County Clerk of the Circuit Court, the Internal Audit
Department has completed an audit of the Health Benefit Program.
The audit objectives were to determine
1. compliance with state and local laws, ordinances, and contracts,
2. policies and procedures properly document the system,
3. internal controls have been established and are being followed and
4. to determine the efficiency and effectiveness of Acordia National and the Keys
Physician Hospital-Alliance (KPHA) in coordinating the plan and to evaluate the
effectiveness of County Management's systems employed to monitor the
Contractor's performance.
II. METHODOLOGY
A. We interviewed the following personnel to obtain information about the Monroe
County Health Insurance Plan:
1. County Administrator
2. Division Director of Management Services
3. Group Insurance Administrator
4. The Clerk's Finance Department personnel
5. Risk Management Consultants at Interisk Corporation representing Monroe County
6. President of Keys Physician-Hospital Alliance
7. Assistant Administrator, Lower Keys Medical Center &
Director of Operations Keys Physician-Hospital Alliance
8. Vice President of Claims at Acordia National
9. Assistant Vice President and Monroe County's Team Manager at Acordia National
10. Chief Operating Officer of Acordia National
11. President of Health Spectrum
12. Director of the Monroe County Health Department
13. Other City and County Health Benefit Plan Managers
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B. Internal Audit Department examined the following documents:
1. Florida Statutes related to Group Insurance Plans
2. Utilization Review Contract between Monroe County and KPHA
3. Administrative Service Agreement between the Board of County Commissioners
of Monroe County and Acordia National
4. Third Party Administrator Agreement By and Between Dimension Health, Inc. and
Third Party Administrator
5. Reaffirmation of Existing Contracts for the Provision of Services under the
Request for Proposal Health Benefit Plan Claims Administration and Utilization
Review Services Presented on September 19, 2001 by Acordia National, Inc. and
Keys Physician-Hospital Alliance
6. Explanation of Benefits (EOB's) from Acordia National -November 2002
7. Monroe County Plan Documents
C. The Internal Audit Department reviewed the contracts to ensure that all terms and
conditions were being complied with as documented within the agreement.
D. Internal Audit reviewed explanation of benefits for proper discounts, deductibles, and
that charges were reduced to 90% of Medicode before the discount was applied.
E. Compared the total amount of prescription paid per month to the total amount of
medical claims paid per month.
F. Compared the Acordia Employee/Dependent File Listing to the EOB's for one month
to ensure claims paid were for eligible participants.
G. Reviewed payments made for dependent coverage.
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III. BACKGROUND INFORMATION
Medical, dental and vision claims of $9,426,645.09 were paid for retirees, employees and
dependents of Monroe County for the fiscal year ending September 2002. This is an increase
of$1,016,734.26 or 12.1% over claims paid of$8,409,910.83 for fiscal year ending September
2001. For the first three months of fiscal year 2003 the paid claims total $2,776,209.59 (31.3%
increase) as compared to $2,114,315.51 for the same time period last fiscal year. Historically,
the amount paid for Monroe County health plan (prescriptions are not included) has increased;
(2000 to 2001 - 11.7%, 1999 to 2000 - 18.7%, 1998 to 1999 - .2%, 1997 to 1998 - (.3%)).
According to Hewitt Associates, a global outsourcing and consulting firm, increases in health
care costs are averaging 15.4% for 2003 renewals,with no forseeable end in sight.
The Group Insurance Function was organized as part of the Employee Benefits Section of the
Human Resource Department. Monroe County has established an employee welfare benefit
plan for the purpose of providing medical, dental, prescription, vision, utilization review and
Cobra benefits for its employees. The authority to provide health insurance and self-insure is
provided by Florida Statute 112.08 (2)(a) which states that "Every local government unit is
authorized to provide and pay out of its available funds for all or part of the premium for life,
health, accident, hospitalization, legal expense, or annuity insurance, or all or any kinds of such
insurance, for the officers and employees of the local government unit and for health, accident,
hospitalization, and legal expense insurance for the dependents of such officers and employees
upon a group insurance plan and, to that end, to enter into contracts with insurance companies
or professional administrators to provide such insurance." Florida Statute 112.08 (2)(a) also
states that "Each local government unit may self-insure any plan for health, accident, and
hospitalization coverage or enter into a risk management consortium to provide such coverage,
subject to approval based on actuarial soundness by the Department of Insurance; and each
shall contract with an insurance company or professional administrator qualified and approved
by the Department of Insurance to administer such a plan."
The County established a self-insurance program for medical, prescription, dental and vision
claims effective July 1, 1996 and changed claims administrators to Acordia National. The
County also began the utilization of a newly foinied preferred provider organization, Keys
Physician Hospital Alliance (KPHA). The Health Benefit Plan currently provides benefits for
the employees of the Board of County Commissioners, the Clerk of the Circuit Court, the Tax
Collector, the Property Appraiser, the Supervisor of Elections, the Sheriffs Department, the
Mosquito Control District and Land Authority. The program is a "self insured" program which
means services are provided through charges to users of the program on a cost recovery basis.
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A. Third Party Plan Administrator Agreement (Acordia National) of the Monroe County
Medical and Dental Plan
On October 1, 2002, the Board of County Commissioners and Acordia National, Inc. (Acordia)
entered into the current Administrative Service Agreement to perform claim administration for
the County's employee welfare benefit plan. See Exhibit A - Administrative Service
Agreement. Acordia National, Inc. is located in Charleston, West Virginia and is a
wholly-owned subsidiary of Acordia, Inc., located in Chicago, Illinois. According to the Ernst
& Young Report on Controls Placed in Operation and Test of Operating Effectiveness for the
period January 1, 2001 to December 31, 2001, Acordia had revenues for the twelve month
period ended December 31, 2001, approximating $30 million. Acordia is a third-party
administrator involving all aspects of design and maintenance of employee benefit plans (e.g.
medical, dental, health care/ dependent care reimbursement, disability) and provides these
services to a diverse group of organizations, primarily in the Eastern United States.
Acordia National profiles its extensive national base. Nonnative data is developed on a
per-1000-member basis and categorized by industry type, deductible level and enrollment size.
Acordia also uses William Mercer research reports to develop comparative measures for
clients. William M. Mercer, in conjunction with Foster Higgins, conducts extensive research
of the health care industry. The firm conducts annual surveys and their publications capture
current industry standards. As part of the audit, Acordia compared Monroe County to other
Acordia clients and to Mercer/Foster Higgins National Statistics. See Exhibit B - Monroe
County Board of Commissions Cost Per Employee Comparison.
B. Keys Physician-Hospital Alliance (KPHA) Employer-Provider Network and
Utilization Review and Case Management Services Agreement for the Monroe County
Health Plan
On July 1, 1996 the Board of County Commissioners and Keys Physician-Hospital Alliance
entered into the Employer-Provider Network and Utilization Review and Case Management
Services Agreement. See Exhibit C - Employer-Provider Network and Utilization Review and
Case Management Services Agreement. The Proposal submitted by KPHA states "The Keys
Physician-Hospital Alliance is a cooperative effort by local physicians, hospital and other
health providers to identify and provide the highest level of care in the most cost-effective
manner. The Keys Health Plan was developed for the self-insured employer to provide a local
community response to the health care needs of the organizations and their employers and
insured. It provides for an integrated health delivery network, which will:
1. Function to identify, develop and maintain access to needed services,
2. Assure appropriate utilization of resources and services,
3. Monitor and maintain the quality of services,
4. Work to control the cost of health care services."
Monroe County is currently the only employer participant in KPHA. Lower Florida Keys
Health System was originally also a participant in the Keys Physician Hospital Alliance. Other
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Networks, such as Beech Street also contract with the KPHA network for access to Monroe
County providers.
Cost Containment
The in county network providers are reimbursed using the 90th percentile of Medicode as a
maximum allowable billed charge. Ingenix bought Medicode and it is now called the MDR
Payment System. It consists of pricing guidelines for physician charges. Ingenix uses a
"blended methodology". Ingenix defines it as "This methodology combines a relative value
scale along with charge data in determining conversion factors to be used in calculating
reimbursement amounts. By using this methodology, relationships between procedures are
used in determining amounts by geozip (geographical area). This allows pricing for procedures
that are new or have low frequency in addition to common procedures." It further states
"Relative values are assigned when Ingenix's Relative Value Committee has an understanding
of how the procedure is billed and how it relates to other procedures. The Relative Value
Committee consists of Ingenix's Medical Director, on-site clinicians, Certified Procedural
Coders and analysts." MDR's data base cross references CPT (procedural) codes to different
percentiles of the specified area's prevailing fees and to average national allowables paid by
indemnity carriers. Monitoring for compliance with the medicode reasonable and customary
charges is a function of the third party administrator and the Plan's Case Management Services.
According to the proposal submitted by KPHA "Providers will accept charges by these
standards as total compensation for services. In-county providers also provide a prompt
payment program. This program provides for a prompt payment discount (PPD) of fifteen
percent (15%) from billed charges if payment is received from payor within 30 days from
submission of a clean claim." Lower Keys Medical Center and Fishermen's provide a prompt
payment discount of 25% from billed charges. The Health plan originally offered a 5% prompt
pay discount off charges for both physicians and hospitals in the KPHA network but increased
the discount as of October 1, 2000. In addition to the KPHA network, Acordia contracts with
another network, Dimension Health, Inc., for additional South Florida providers. The proposal
from Acordia states that discounts achieved from the Dimension Network averages about 30%,
however, due to the proprietary nature of the fee schedule it was not included in the proposal.
C. Employee Benefits Function
The Group Insurance Function is organized as part of Administrative Services Department.
The method used by the Monroe County Group Insurance Function for group insurance claims
processing is direct submission. Participants and providers submit claims directly to Acordia
National using the direct submission method.
After Acordia National receives and processes the claim forms, a payment register is produced
by the system. One copy of the register is sent to Employee Benefits. The Employee Benefits
Department verifies the register to ensure that all claims being paid are for covered employees
and their dependents.
Another copy of the payment register is faxed to the Clerk's Finance Department. The Clerk's
Finance Department transfers the funds necessary to pay the claims to the bank account that the
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checks are drawn on. The bank account is owned by Monroe County but the checks are issued
and mailed from Acordia. The authority for Acordia National to issue claims checks on the
Monroe County bank account is provided by Florida Statute 136.091 which states that "A
board of county commissioners is authorized to contract with an approved service organization
to provide self-insurance services, including, but not limited to, the evaluation, settlement, and
payment of self-insurance claims on behalf of the board. Pursuant to such contract, the board
may advance money to the service organization to be deposited in a special checking account
for paying claims against the board under it's self insurance program."
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IV. Audit Conclusions:
Al. Prompt pay discounts were not calculated correctly by Acordia National. Prompt pay
discounts of 15% on physician bills should be calculated based on the lower of billed
charges or the 90th percentile of Medicode. Acordia, the third party administrator
calculated the 15% discount on total billed charges (instead of calculating it on the
lower of billed charges or the 90th percentile of Medicode). They subtracted the
discount and then supposedly compared the net amount to the 90th percentile of
Medicode. Of the 971 claims tested for November 2002, there were no claims for in
county providers that were reduced to the 90th percentile of Medicode. Acordia's
preliminary estimate of the overpayment for 2000 through 2003 is $156,534.03.
A2. Acordia National processed physician claims for the KPHA Network using the 90th
percentile of the 1997 Medicode Fee Schedule for the usual and customary
comparison. KPHA had not provided Acordia with the new releases of the Fee
Schedule that are issued twice each year.
A3. Nine KPHA providers were added to Acordia's system incorrectly. The first provider
was not updated with the 15% discount effective October 1, 2000, a 10% discount was
added erroneously. The total amount processed with the wrong discount was
$37,227.46. The second provider was added as a KPHA provider on October 25,
2002 with a 5% discount, but is not a member of KPHA and was added incorrectly.
The amount of claims processed with a 5% discount after October 25, 2002 was
$9,595.29. The third provider was added without a 15% discount and the total
amount billed without a discount was $8,975.00. Five providers were added with a
5% discount and the correct discount is 15%. The total amount processed for these
providers were $334,179.90. The ninth provider was added without a 15% discount
and the total amount billed without a discount was $69,493.42.
A4. Claims were erroneously paid for two nurse practitioners. Nurse practitioners are not
listed in the summary plan description (plan booklet) as covered providers.
A5. During the examination of claims, it was determined that three providers belong to
both the Dimension network and the KPHA network. The claims of these three
providers were processed using the smaller Dimension discount of 10% rather than
the larger KPHA discount of 15%.
Bl. The initial plan with direct submission of claims included the Group Insurance
Department doing random claims inquiry. A program of random audits and inquiries
should be established on a periodic basis to ensure that the plan is functioning as
intended.
B2. Written instructions provided on the payment of claims by Group Insurance
Management and KPHA to the third party administrator are not always implemented.
Many of the audit findings in this report are the result of changes not being
implemented correctly. Group Insurance Management should consider including an
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acknowledgment form to be signed by Acordia Management stating the required
changes were made and the date it was implemented.
Cl. Two KPHA providers were paid as Out of Network claims because the providers are
billing with more than one tax identification number.
C2. Numerous Dimension provider claims are paid as referrals, but the providers are
participants in the Dimension Network. A laboratory joined the Dimension Network
on January 1, 1999 and was paid $118,963.62 as a referral and should have been paid
as a Dimension provider.
D. There were 12 Dimension claims totaling $8,764.06 which were paid over reasonable
and customary. The total amount paid over the 90th percentile of Ingenix was
$2,629.97. Some contracts with Dimension providers are based on a straight
percentage discount off of billed charges and other Dimension contracts have a fee
schedule allowed for each procedure code. The Dimension contracts that are based on
a straight percentage off of billed charges are not compared to any reasonable and
customary fee schedule.
El. Failure of some County entities to communicate employee changes to Group
Insurance in a timely manner can result in overpayment of benefits.
E2. Five terminated employees were listed as active on the January 2, 2003 Acordia
Employee/Dependent File Listing. In addition, one dependent was listed as active,but
should have been deleted from dependent coverage.
Fl. The right to audit clause in the Employer-Provided Network and Utilization Review
and Case Management Services Agreement allows Acordia the right to audit, but does
not allow Monroe County the right to audit KPHA's records.
F2. The In County network providers are reimbursed at a maximum of the usual and
customary charge rate of the 90th percentile of Medicode. Medicode is a healthcare
information company that provides physician charge data. Interisk, Inc., (insurance
consultant) states that the current trend is toward using lower percentiles of usual and
customary charges. Most of Interisk's customers are using between 80% to 85% of
usual and customary rate schedules.
G1. Not-for-profit reports were not submitted as requested. Although, KPHA was
organized as a Florida not-for-profit corporation, the Physician-Hospital Organization
(PHO) is not a tax-exempt entity and has never applied for tax-exempt status from
either the Federal Government or the State of Florida. KPHA has always maintained
the independence of their organization by stating it is not a part of the hospital, they
are a separate organization with a separate board of directors. KPHA performs
utilization review procedures for Monroe County, therefore, having responsibility for
reviewing and denying procedures and hospital stays requested by physicians that
belong to their own organization. Independence in the performance of their utilization
process is essential for the cost effectiveness of the plan and provides for objective
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and uninhibited appraisal.
G2. As part of the audit and at the request of the auditors, Acordia analyzed the utilization
review procedures of KPHA for six Large Case Management patients with numerous
claims. Acordia states "Overall the utilization review appears consistent with industry
standards." KPHA should enter clinical documentation directly into Acordia's claim
system for Nurses and Claims Examiners to make decisions on claims.
G3. According to Interisk Management, it is customary within the industry for large
hospital bills to be referred to outside vendors for analysis. One recent hospital stay
was billed at $250,000 and would be a good candidate for analysis by an outside
vendor.
H. The Employee Benefit Health, Dental and Vision plan document is dated October 1,
1996. Amendments have been made to the plan and Group Insurance Management
should consider revising the plan document.
I. Group Insurance Management stated that payment for surgical procedures should be
calculated according to Medicare's Multiple Surgery Guidelines and was under the
assumption that Acordia was using this method. Using Medicare's guidelines the
payment for a second surgical procedure performed during an operation is reduced to
50% for the second procedure. Acordia's method of payment is to reduce the second
procedure to 50% only if it is performed through the same incision as the primary
procedure.
J. Chiropractic and Massage Therapy visits totaled $15,236 for the audit test period and
represents 5% of the total test amount. Most physician bills reviewed for the audit test
period were billed with three to six procedure codes per visit. Group Insurance
Management should consider having KPHA review the chiropractic and massage
therapy billing to see if further oversight is necessary, such as pre-certification or
additional limits on the benefits.
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A. Third Party Administrator's Calculation of Payments to Providers
The auditors tested 971 claims paid in November 2002. Total paid claims for
November 2002 were $1,119,946.04. Numerous problems were found within the test
data. The breakdown of the claims in the test data is as follows:
#of Claims Total Paid % of Total
In Network KPHA Claims 546 $144,055.63 48.3%
In Network Dimension Claims 126 $45,358.62 15.2%
Out of Network Claims 299 $109,082.83 36.5%
Total 971 $298,497.08 100.0%
1. Prompt Pay Discounts -In Network KPHA
Finding:
The auditors tested 971 claims paid ($298,497.08 dollars tested) in November 2002
of which 546 claims ($144,055.63) or 48.3% were in the KPHA network to
determine if the claims were properly paid. Several problems were found with the
calculations. Prompt pay discounts of 15% were applied to total billed charges by
Acordia National. This 15% discount is then subtracted from total billed charges and
the net amount is then compared to Medicode's 90th percentile. According to
Acordia, if this net amount exceeds the amount for the 90th percentile of the
particular CPT code the difference will be disallowed and neither the County or the
employee is responsible for payment. However, of the 971 claims tested for
November 2002, there were no claims for in county providers that were reduced to
the 90th percentile of Medicode. According to the Agreement and the intention of
the plan, the third party administrator should first compare the billed charge to the
90th percentile of Medicode, reduce it if necessary to the 90th percentile and then the
15% prompt pay discount is applied. See Exhibit D - KPHA Letter Defining
Contract Prompt Pay Discount. The contract states the following:
Provider Reimbursement Terms: KPHA shall use best efforts to ensure that
the Participating Provider's physician Usual Customary and Reasonable (UCR)
charges will not change during the term of one year. Thereafter, KPHA agrees
to provide a ninety (90) day notification in the event of a charge increase.
Physician UCR charges will be based upon "the Medicode database." The
above agreed upon discount will be applied to the billed charge, not to exceed
the UCR charge for a service.
Participating Provider Compensation: All claims for covered services,
whether payable by the Employer or a Covered Person will receive a discount
off of provider billed charges as specified in Attachment A. This discount will
be rescinded if an appropriately documented and non-contested claim is not paid
to the Participating Provider within thirty (30) days of being received by the
claims administrator(Acordia National).
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The following claim payment example demonstrates the difference between
Acordia's actual method of payment using the 1997 Medicode Fee Schedule and the
correct method of payment according to the agreement and intention of the plan:
Acordia's Method of Actual Amount Paid:
1997 90th Not 15% Prompt 80% Employee
CPT Code Charges Percentile Covered Pay Discount Covered Paid Portion
99204 $286.00 $182.32 $0.00 $42.90 $243.10 $194.48 $48.62
According to KPHA and the Intention of the Plan:
1997 90th Not 15% Prompt 80% Employee
CPT Code Charges Percentile Covered Pay Discount Covered Paid Portion
99204 $286.00 $192.32 $103.68 $27.35 $154.97 $123.98 $30.99
Claim Overpayment $103.65 ($15.55) $88.13 $70.50 $17.63
The amount overpaid to the provider for this claim is $88.13. Overpayment by
the County is $70.50 and overpayment by the employee is $17.63 using the above
example. See Exhibit E - Acordia Explanation of Benefits.
Acordia National is also using a Medicode Fee Schedule that is six years old. See
Finding -A-2 1997 Medicode Fee Schedule Used For Comparison of Reasonable and
Customary Charges.
Acordia's method of calculating the 15% prompt pay discount results in the County
not receiving a prompt pay discount from physicians charging at or above the 90th
percentile of Medicode's usual and customary charges. During the audit, it was
discovered that initially Acordia was calculating the discount correctly according to
the County and KPHA's interpretation. Acordia's preliminary schedule of
overpayment is as follows:
Claim 90th Percentile
Examiner Employee Medicode Employee Total
Year Error Portion Not Updated Portion Overpayment
2003 $4,910.31 $1,026.38 $1,618.49 $250.35 $7,805.53
2002 $46,121.99 $8,134.70 $6,908.55 $1,324.26 $62,489.50
2001 $34,786.09 $6,598.56 $11,883.27 $1,965.61 $55,233.53
2000 ($3,455.95) ($1,073.38) $32,467.39 $3,067.41 $31,005.47
Total . $82,362.44 $14,686.26 $52,877.70 $6,607.63 $156,534.03
Acordia's management produced computer reports to determine the extent of the
overpayment. From analysis of claims processed in previous years, it appears that in
2001 Acordia began calculating the claims incorrectly.
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Recommendation(s):
1. Group Insurance Management should ensure that Acordia National calculates
prompt pay discounts according to the terms of the KPHA Proposal and
Agreement.
County Administrator's Response:
Management agrees with recommendation. Although questions were raised about the
ever increasing costs, full, detailed information has not been available. We obtained
the basic information through another channel. Senior Management for Management
Services requested a comparison between Medicode and another Code, Health
Insurance of America, to see if a cost reduction could be obtained. It could not.
However, the information received allowed the Auditors to investigate the proper
handling of claims under Medicode. Acordia has been advised by both KPHA and
Monroe County of the proper handling of claims under Medicode. (See attached
letters)
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2. 1997 Medicode Fee Schedule Used For Comparison of Reasonable and
Customary Charges
Finding:
Acordia National processes physician claims for the KPHA Network using the 90th
percentile of the 1997 Medicode Fee Schedule for the usual and customary
comparison. See Exhibit F - KPHA Network Payments Memo. According to
Richard Legg, Sr. VP/COO., at Acordia National "We take the total charge and
multiply it by 15%, and then compare it with the 1997 Medicode Fee Schedule that is
loaded in our system and allow the lesser amount of the two." He further states "In
addition, we have had several providers that have questioned the old fee schedule and
have informed us that their contract says it is a 15% discount, so we have used this
figure rather than the fee schedule, once again because it is over 6 years old."
Acordia stated that they have informed KPHA numerous times that the fee schedule
is outdated. KPHA is receiving the updates from the software company and stated
that their software company is supposed to send updates directly to Acordia. County
Management meets with Acordia National and KPHA personnel on a monthly basis
to discuss the plan and were never advised by Acordia or KPHA there was a problem
with the fee schedule.
The proposal submitted by KPHA states the following:
In County Network Providers: The in county network providers are
reimbursed at a usual and customary charge rate as established by "Medicode," a
company that established standard charges for all procedures and services.
Monitoring for compliance with these charges is a function of the third party
administrator and the Plan's Case Management Services. Providers will accept
charges by these standards as total compensation for services. In-County
providers also provide a prompt payment program. This program provides for a
prompt payment discount (PPD) of fifteen percent (15%) from billed charges if
payment is received from payor within 30 days from date of submission of a
clean claim.
Based on the 1997 fee schedule and method Acordia was using to determine
reasonable and customary charges for our test month Acordia overpaid $6,010.64 on
71 claims, using an updated Medicode Fee Schedule Acordia overpaid $5,104.80.
After discussions of certain claims with Internal Audit, Acordia states "Due to
complexities with this old fee schedule, we have discovered that we have used the
15% discount in situations where we should have used the fee schedule. We are
reviewing this to see if adjustments to some claims need to be done." See Exhibit G-
Acordia's Preliminary 2003 Schedule of Overpayments.
If an updated Medicode Fee Schedule (November 2002) had been used for the
example from the previous finding the overpayment would be $24.75, $19.80
overpaid by the County and$4.95 overpaid by the employee.
13
Acordia's Method of Actual Amount Paid:
1997 90th Not 15% Prompt 80% Employee
CPT Code Charges Percentile Covered Pay Discount Covered Paid Portion
99204 $286.00 $182.32 $0.00 $42.90 $243.10 $194.48 $48.62
According to KPHA and the Intention of the Plan:
2002 90th Not 15% Prompt 80% Employee
CPT Code Charges Percentile Covered Pay Discount Covered Paid Portion
99204 $286.00 $256.88 $29.12 $38.53 $218.35 $174.68 $43.67
Claim Overpayment $29.12 ($4.37) $24.75 $19.80 $4.95
Recommendation(s):
1. Group Insurance Management should ensure that the contract defines
responsibility for providing the medicode usual and customary database and
monitor the contract appropriately.
2. Group Insurance Management should coordinate the refund process with Acordia.
County Administrator's Response:
Management agrees with recommendation and will propose contract amendments
regarding updating of code and will seek a resolution of overpayments.
14
3. KPHA Providers Added to Acordia's System Incorrectly
Finding:
Nine providers were added to Acordia's system incorrectly. Of the nine, eight of the
providers were KPHA and added to Acordia's system with incorrect discounts or
without a discount. The pathologist was a Dimension provider, but was entered into
Acordia's system as a KPHA provider erroneously.
Date KPHA/ Corrected
Amount Entered Acordia Dimension Discount
Billed In Acordia Discount% Discount % Amount
Gynecologist $37,227.46 10/01/2000 10% 15% $1,861.37
Pathologist $9,595.29 10/25/2002 5% 10% $479.76
Diagnostic Center $8,975.00 10/01/2000 0% 15% $1,346.25
Dentists (5) $334,179.90 10/01/2000 5% 15% $33,417.99
Medical Equipment $69,493.42 10/01/2000 0% 15% $10,424.01
Total $47,529.39
The discount affects both the amount paid by the County and the employee and it
would also reduce the amount that accumulates toward the employees deductible.
Acordia has corrected the KPHA provider discounts to 15% for future payments after
discussions with internal audit.
Incorrect payments would have continued indefinitely since the set-up did not contain
accurate information. Acordia should furnish KPHA a provider listing with tax
identification numbers and discount percentages allowed to review and correct on a
periodic basis.
Recommendation(s):
1. Group Insurance Management should coordinate the adjustment process with the
third party administrator.
County Administrator's Response:
Although it was not part of the formal recommendation, Management will request
Acordia furnish a provider listing with tax identification numbers to KPHA on a
periodic basis to review and correct (if necessary) discount percentages.
Management will seek resolution for claims processed with incorrect discount.
15
4. Claims Paid For Two Ineligible Providers
Claims were erroneously paid for two nurse practitioners. Nurse practitioners are not
listed in the summary plan description (plan booklet) as covered providers. One of
the nurse practitioners billed 30 claims totaling $2,963.00 from September 13, 2001
through February 6, 2003 and the third party administrator paid $648.72. The second
nurse practitioner billed 19 claims totaling $2,132.00 from October 29, 2001 through
March 12, 2003 and the third party administrator paid $733.51. Some of the claims
were paid and others were denied with the EOB explanation stating it was an
ineligible provider. Since nurse practitioners are not covered by the plan, Acordia is
processing refund requests for those items paid in error. The two providers are
members of the KPHA network and they are listed in the KPHA provider listing. If
the plan intends to cover these providers in the future, the plan document should be
amended.
Recommendation[ :
1. Group Insurance Management should coordinate the adjustment process with the
third party administrator.
County Administrator's Response:
Management has been approached by KPHA to add Nurse Practitioners as covered
providers under the plan. They can be added at the next plan document change.
Management will seek resolution for incorrect processing of providers.
16
i
5. Providers in Both KPHA and Dimension Networks Paid Using Smaller Discount
Finding:
During the examination of claims, it was determined that three providers belong to
both the Dimension Network and the KPHA Network. The claims of these three
providers were paid using the Dimension discount of 10% rather than the larger
KPHA discount of 15%. The total claims paid in the test period for the three
providers was $2,670. Acordia is producing reports to indicate the amounts paid
using the smaller Dimension discount.
Acordia's Management stated that they can not just take the largest discount because
the Claims Examiner would have to process the claim twice. Acordia needs to be
instructed which network to use if a provider is a member of both. For these three
providers the Dimension discount is lower and the KPHA discount should have been
used. Group Insurance Management should inquire of Acordia if they can make
changes to their system so the highest network discount is used to process the claim.
However, if Acordia is unable to automate this function, Group Insurance
Management should research and instruct Acordia on which network to use as the first
priority. However, this priority should be monitored as discounts change within the
networks (originally KPHA's discount was 5% and then increased to 15% for
physicians and 25% for hospitals). For example, Dimension offered a 16% discount
at Baptist, according to Interisk's Audit of Medical Benefit Claim Administration May
1998, and now the discount has been reduced to 10%. The new Multiplan network
should also be considered when Group Insurance Management sets the priority of
which network to use. A specific procedure to determine which discount applies will
assist Acordia in properly adjusting claims as well as reduce the overall claim
payment amount.
Recommendation(s):
1. Group Insurance Management should establish a written procedure for applying
discounts where providers are members of multiple networks.
2. Group Insurance Management should establish a program of audits and inquiries
on a periodic basis to ensure that the plan is functioning as intended.
County Administrator's Response:
Management has been told by KPHA on several occasions that when a provider was
a member of multiple networks, the claims were processed using the network that
gave the greater discount. Recently Acordia stated that this cannot be done.
Management will request an additional attempt to have this programmed into their
process. If this change can not be made, direction would be to use KPHA for Monroe
County providers, Dimension for providers in Miami-Dade, Broward and Palm
Beach Counties, and Multi-Plan for all other locations.
The Muli-Claim Lease Agreement (when completed) will allow on-line access to
Acordia information and facilitate doing audits of this activity.
17
6. Miscellaneous Errors
Finding:
A review of physician bills related to the audit sample revealed the following
miscellaneous problems:
One dental claim #23853 for a fluoride treatment for a child (procedure code 01203)
was billed at $26.00, but the claim was incorrectly calculated by the Claims Examiner
and paid at$260. A refund was requested during the audit.
On one outpatient hospital bill totaling $264.20 the 25% discount was not taken due
to the Claims Examiner erroneously applying a manual override. A refund of$66.05
was requested during the audit.
Recommendation(s):
1. Group Insurance Management should establish a program of audits and inquiries
on a periodic basis to ensure that the plan is functioning as intended.
2. Group Insurance Management should coordinate the adjustment process with the
third party administrator.
County Administrator's Response:
Management will seek resolution to the adjustment process. The nature of the above
claims that were processed incorrectly was not through a fault of the system, but
human error. Hopefully, with periodic audits by the Group Insurance Management,
the likelihood of future errors will be decreased. The County's insurance consultant
will assist in devising a program of audits and inquiries.
•
18
B. Monitoring
1. Monitoring Of Claims Not Implemented
Finding:
The initial plan with direct submission of claims included the Group Insurance
Department doing random claims inquiry. According to Interisk's Audit of Medical
Benefit Claim Administration May 1998, Acordia would provide the needed software
adjustments to permit full access to the same computer records that Acordia claim
examiners use. With full access to computer information and the ability to print out
individual records, the County can perform a random continuous audit on a weekly
basis. Group Insurance also receives a copy of the explanation of benefits. Internal
Audit reviewed explanation of benefits for proper discounts, deductibles, and that
charges were reduced to 90% of Medicode before the discount was applied. The
Internal Audit Department provided Group Insurance with a spreadsheet that was
used in the audit to detect payments that were incorrectly calculated. Group
Insurance might consider adding some of the questions used by Interisk in the claim
file audit checklist in the monitoring process. See Exhibit H - Claim Worksheet and
Claim File Audit Checklist. The actual physician bill can be requested if a payment
appears questionable for any reason. Errors detected can be corrected by Acordia
more quickly and recovery of any claims paid in error may be more likely.
The Internal Audit Review of Monroe County Group Health Insurance completed
June 1998 recommended that a program of random audits and inquiries should be
established on a periodic basis to ensure that the plan is functioning as intended and
to control any risk of fraud. The random audits and inquiries were not implemented
by County Management.
Recommendation(s):
1. Group Insurance Management should require Acordia National to provide remote
access to all claim software and claim detail files and all necessary training.
2. Group Insurance Management should establish a program of audits and inquiries
on a weekly basis to ensure that the plan is functioning as intended.
County Administrator's Response:
The Board of County Commissioners has approved a Multi-Claim Lease Agreement
that is currently being executed. This will provide access to do random audits and
inquiries on claims processed. These audits will begin as soon as lease is fully
processed. This should address the above recommendations. The County's
insurance consultant will assist in devising a program of audits and inquiries.
19
2. Written Confirmation of Changes
Finding:
Group Insurance had given written instructions to Acordia and to KPHA to make
many changes that are findings in the current audit report. For example, Group
Insurance Management asked numerous times at meetings if the medicode was
current and was never told that there was a problem. Acordia was using version that
was six years old. Medicode should have been updated with new releases twice each
year.
When the change was made for the KPHA providers to grant a 15% discount, the
change should have been implemented October 1, 2000, but it was not updated until
October 22, 2000. Another problem occurs with providers that are in more than one
network. Monroe County had instructed Acordia to always take the largest discount.
However, it was not until a February 2003 meeting that Acordia Management
indicated that Group Insurance has to specify which network takes priority.
Acordia's computer system would have to process the claim twice in order to take the
largest discount.
Acordia Management claims they do know always receive changes from Group
Insurance or the Networks. Due to the confusion surrounding how Acordia was
processing some of the health claims and to enhance communication and
documentation, Group Insurance Management should send written documentation to
Acordia of any changes to be made and require written confirmation of the date the
changes were implemented and be signed by a representative from Acordia.
Recommendation(s):
1. Group Insurance Management should consider including an acknowledgment form
to be signed by Acordia Management that states the required change was made
and the date it was implemented.
County Administrator's Response:
Management concurs with the above recommendation and will implement with
further plan changes and/or processing revisions.
20
C. Provider Claims Paid as Out of Network Claims
1. KPHA Provider Claims Paid as Out of Network Claims
Finding:
Two KPHA providers are billing with more than one federal tax identification
number. One provider billed 74 claims totaling $23,989 and the third party
administrator paid $12,384.14. The second provider billed 462 claims totaling
$140,804 and the third party administrator paid $79,980.46. The claims were paid as
out of network claims (70% coinsurance percentage and no discount) because the tax
identification number did not match the one provided to Acordia by KPHA.
According to Acordia Management, this is a common issue for all networks.
Providers don't always notify the networks when their tax identification numbers
change and it ultimately results in claims being paid out of network. A provider can
only be matched to a specific network if they bill their claims with the tax
identification number provided to Acordia by the network. However, in at least one
situation, KPHA had notified Acordia on August 31, 2001 of the correct tax
identification number to be used. KPHA plans to provide both social security
numbers and tax identification numbers to Acordia to update their claim system for
all KPHA providers.
Recommendation(s):
1. Group Insurance Management should establish a program of audits and inquiries •
on a periodic basis to ensure that the plan is functioning as intended.
County Administrator's Response:
The implementation of the Multi-Claim Lease Agreement will allow Group Insurance
Management to audit the processing to find these errors. Acordia will also be
required to do periodic sorts of the providers to help eliminate errors that are outlined
above. The County's insurance consultant will assist in devising a program of audits
•
and inquiries.
21
2. Dimension Provider Claims Paid as Referrals
Finding:
Numerous Dimension provider claims are paid as referrals, but the providers are
actually participants in the Dimension Network. Providers paid as referrals are paid
at the in network rate of 80% or 100%. A laboratory that joined the Dimension
Network on January 1, 1999 had 783 claims totaling $118,963.62 processed as
referrals and the claims should have been paid based on the Dimension Fee Schedule.
For example, one procedure code (80055) had a charge of$363.26 and Acordia paid
$174.40. The Dimension Fee Schedule amount was $62.35. Therefore, Acordia
should have only paid $49.88 (80% of $62.35). The overpayment for Monroe
County's 80% portion on this one CPT code was $112.05. A claim should only be
processed as a referral if it is not a network provider. In a letter dated January 20,
1999, RE: Exclusion of Out of Network Services, Group Insurance Management
states "We would like to suggest that the following services be paid as though they
were in network only if provided by/or in an in-network Health Care Facility or an
in-network physician - Laboratory and/or Pathology Services". See Exhibit I -
Exclusion for Out-of-Network Services. A list of other Dimension providers
processed as referrals or out of network claims has been provided to Acordia for
correction.
Recommendation(s):
1. Group Insurance Management should establish a program of audits and inquiries
on a periodic basis to ensure that the plan is functioning as intended.
2. Group Insurance Management should consider notifying Acordia that the
exclusion no longer applies since the County has three participating networks.
County Administrator's Response:
Management believes claims should always be processed as network provider and if
no network shows up, the system should check for referral before decision to assess
penalty. The referrals are general lab tests and the quantity of them should not be
prohibitive for checking. The referral status is on the claim form and will be required
by Acordia to prevent this problem in the future. The County's insurance consultant
will assist in devising a program of audits and inquiries.
22
D. Certain Dimension Claims are Paid Over Usual and Customary
Finding:
The Employee Benefit Plan Document states in Section 9 - Medical Exclusions (20)
that no payment will be made under this Plan in any event for charges which exceed
reasonable and customary. Reasonable and Customary is defined in Section 12 -
Definitions, as follows:
Section 12 - Definitions Reasonable and Customary: the charge made by a
Physician or supplier of services, medicines, or supplies which does not exceed.
the general level of charges made by others rendering or furnishing like services,
medicines, or supplies, within the area in which the charge is incurred for
sickness or injury comparable in severity and nature to the sickness or injury
being treated. The term area, as it would apply to any particular service,
medicine, or supply means a county or such greater area as is necessary to
obtain a representative cross-section of level of charges.
Some contracts with Dimension providers are based on a straight percentage discount
off of billed charges and other Dimension contracts have a fee schedule allowed for
each procedure code. The auditors tested 971 claims paid ($298,497.08 dollars
tested) in November 2002 of which 126 claims ($45,358.62) or 15.2% were in the
Dimension network to determine if the claims were properly paid. There were 12
Dimension claims totaling $8,764.06 which were paid over usual and customary
charges in the test. The total amount paid over the 90th percentile of Ingenix was
$2,629.97. KPHA established the use of the 90th percentile of Medicode to
determine reasonable and customary for their providers before the prompt pay
discount is applied. Out of network claims are compared to the Ingenix fee schedule
provided by Acordia and charges are reduced if the Ingenix amount is lower. The
Dimension contracts that are based on a straight percentage off of billed charges are
not compared to any reasonable and customary fee schedule. This results in the
County paying more with a 10% discount given by the provider than if the employee
had used an out of network physician. For example, on one of the 12 claims over
usual and customary the Dimension provider billed for $1,698.56 for 4 units of
procedure code 88305, the Ingenix 90th percentile would have allowed $600 for 4
units. The County's 80% portion to pay would have been $480 and the County
actually paid $1,528.72. Interviews with Dimension personnel revealed that the
problem with the flat percentage is mainly with physicians located in Monroe County
because it is a small negotiated provider discount and it is not compared to any
reasonable and customary fee schedule.
Recommendation(s):
1. Group Insurance Management should discuss with Dimension the problems
identified in the audit and a proposal to correct this deficiency in the future.
23
County Administrator's Response:
Dimension Health physicians are contracted to work under a fee schedule. However,
this is not the case for doctors contracted by Dimension in Monroe County (mostly
upper keys), where the Dimension contract calls for a discount off of charges. In the
case of those doctors, the discount is off their normal charges and the Dimension
contract does not have the provision where charges can be compared to a fee
schedule. The terms of the Dimension contract with these doctors are what determine
how they are paid.
Dimension will be asked to go back to these doctors and try to re-contract with them,
with the new contract including a fee schedule cap. At that point, Acordia could
implement the same arrangement currently in place with KPHA physicians.
24
E. Maintaining Eligible Member Records
1. County Entities and Departments Not Reporting Employee Changes Timely
Finding:
A review of employee eligibility within the Monroe County Group Insurance Office
identified employing County entities and departments are not always reporting
employee changes on a timely basis. Group Insurance personnel are responsible for
maintaining the eligibility records and they rely on the County entities and
departments to report employee terminations, leave of absences, new hires,
retirements and dependent information with the corresponding effective date. A
sample test of terminations entered in Acordia's system by Group Insurance
personnel ranged from 11 days prior to termination and up to 60 days after
termination.
Failure of the County entities and departments to communicate employee changes to
Group Insurance in a timely manner can result in overpayment of benefits for
ineligible employees and their dependents. An interview with Group Insurance
personnel indicated the Sheriff's Department, Social Services and Mosquito Control
have had trouble in the past reporting changes timely. Group Insurance notified the
entities through memos of the necessary requirements to report employee changes.
This has improved the reporting of employee changes. However, due to the large
number of participants and numerous employers and departments within the plan, all
County entities and departments would benefit from documentation of the eligibility
notification procedures.
Recommendation(s):
1. Group Insurance Management should establish and implement an Administrative
Instruction to provide guidelines regarding procedures on notification
requirements and the responsibility of County departments and entities for
employee terminations, leave of absences, new hires, dependent eligibility and
retirements.
County Administrator's Response:
Many of the entities covered under the group health program do not come under the
responsibility of the County Administrator; therefore they would not be covered
under Administrative Instructions. Management will periodically remind the various
entities and departments of the need for prompt notification of any terminations,
retirements, etc. Others will be developed for a procedure for reminding the various
entities of the importance of prompt reporting of payroll changes and also to cover
the correct procedure for BOCC employees.
25
2. Terminated Employees and Dependents Listed As Active On Acordia
Employee/Dependent File Listing
Finding:
To ensure claims paid were for eligible participants, the auditors compared the
Acordia Employee/Dependent File Listing dated January 2, 2003 to the December
2002 Group Insurance Billing and the November 2002 Employer Listings. Five
terminated employees were listed as active on the January 2, 2003 Acordia
Employee/Dependent File Listing. In addition, one dependent was listed as active but
should have been deleted from dependent coverage.
Group Insurance personnel fax each employee change or termination to Acordia
because the system access available to them for Acordia is too slow. According to
Interisk's Audit of Medical Benefit Claim Administration May 1998, Acordia would
provide the needed software adjustments to permit full access to the same computer
records that Acordia claim examiners use. Full access to Acordia's system was not
implemented.
Group Insurance should enter all employee activity directly into Acordia's claim
system. Maintaining an accurate and up-to-date list of eligible members of the
Health Plan is essential to ensure that benefits are allowed only for eligible
individuals.
Recommendation(s):
1. Group Insurance Management should require Acordia National to provide remote
access to all claim software and claim detail files and all necessary training.
2. Group Insurance Management should enter all employee activity directly into
Acordia's claim system and monitor the Employee/Dependent File Listing for all
the changes made.
County Administrator's Response:
Management believes the Multi-Claims Lease Agreement will allow these
recommendations to be implemented.
26
F. Agreements
1. Right to Audit Clause in Employer-Provided Network and Utilization Review
and Case Management Services Agreement
Finding:
The Employer-Provided Network and Utilization Review and Case Management
Services Agreement is between Keys Physician-Hospital Alliance and the Monroe
County Board of County Commissioners. The right to audit clause in the contract
allows Acordia (the third party administrator) the right to audit but does not allow the
County access to KPHA's records. The contract states "KPHA shall make available
to claims administrator (Acordia National) all records and other data relating to both
the network and utilization and case management services for the purpose of periodic
audits of KPHA's services. Information/data will be maintained, as required, to
assure confidentiality and compliance with all applicable regulations." As part of our
standard audit procedures, we requested KPHA's financial statements. At first
KPHA refused to allow us access to the financial records. After discussion, KPHA
sent us their financial statements, but not the related trial balance as well as a letter
stating their attorney's opinion that our contract does not allow the County access.
See Exhibit J - Letter from Lower Keys Medical Center on KPHA's Contractual
Obligation to Monroe County.
All Monroe County agreements should include a right to audit clause in order for the
Internal Audit Department to properly monitor the effectiveness of the contract.
Recommendation:
1. Group Insurance Management should include a right to audit clause for the County
in the Agreement with KPHA.
County Administrator's Response:
Management agrees with recommendation and will include in all future agreements.
27
2. Usual and Customary Reimbursed at 90% of Medicode
Finding:
The In County network providers are reimbursed at a maximum of the usual and
customary charge rate of the 90th percentile of Medicode. Medicode is a healthcare
information company that provides physician charge data. The usual and customary
charges used for reimbursement are geographic and zip code specific. Medicode's
Customized Fee Analyzer cross references CPT (procedural) codes to different
percentiles of the specified area's prevailing fees and to average national allowables
• paid by indemnity carriers. Interisk, Inc., (insurance consultant) states that the
current trend is toward using lower percentiles of usual and customary charges. For
example, most of Interisk's customers are using between 80% to 85% of usual and
customary rate schedules.
Percentiles are frequently misunderstood. Based on Medicode's methodology and
databases, if your fee for a given service is at the 90th percentile, only 10% of the
submitted charges for that service are higher than your fee. Medicode's Customized
Fee Analyzer states the following about the 95th percentile "This figure is included
so that health care professionals can see as complete a picture as possible, but it is
often inadvisable to bill at this level. In the current political atmosphere of cost
containment, consistent high level billing can be harmful to the financial well-being
of your practice."
Group Insurance Management should consult with KPHA and Interisk regarding the
consequence of using a lower level of usual and customary reimbursement versus the
current 90% level, which may lower the cost of the plan.
Recommendation(s):
1. Group Insurance Management should consider renegotiating the percentage of
Medicode used for the reasonable and customary rate schedule.
County Administrator's Response:
Management agrees with the recommendation and will pursue a lower percentage of
Medicode.
28
G. Utilization Review
1. Independence
Finding:
As part of our standard audit procedures, we requested KPHA's Form 990 Return of
Organization Exempt from income tax. An organization's completed Form 990 is
available for public inspection as required by Section 6104 of the Internal Revenue
Code. Lower Florida Keys Physician/Hospital Organization, Inc., is organized as a
Florida not-for-profit corporation doing business as Keys Physician-Hospital
Alliance. KPHA has always maintained the independence of their organization by
stating that it is not part of the hospital, they are a separate organization with a
separate board of directors.
Form 990 was not submitted as requested. The Executive Director of KPHA states
"Please note that although the PHO was organized as a Florida not-for-profit
corporation, the PHO is not a tax exempt entity and has never applied for tax-exempt
status from either the Federal Government or the State of Florida. Therefore, the
PHO cannot comply with your request for copies of any application for tax
exemption or Form 990's for the past three years." See Exhibit K - Letter from
Executive Director on Return of Organization Exempt From Income Tax.
KPHA performs utilization review procedures for Monroe County, therefore, having
responsibility for reviewing, approving or denying procedures and hospital stays
requested by physicians that belong to their own organization.
The Assistant Administrator of the Lower Keys Medical Center is also the Director of
Operations for the Keys Physician-Hospital Alliance. Independence in the
performance of their utilization review process for both prescription management and
the health plan is essential for the cost effectiveness of the plan.
Recommendation(s):
1. County Management should obtain clarification of the relationship between
KPHA and Lower Keys Medical Center and whether or not there are any
independence issues that may negatively affect KPHA's ability to act on behalf of
Monroe County pursuant to the Employer-Provider Network and Utilization
Review and Case Management Agreement.
County Administrator's Response:
Management will attempt to clarify the relationship.
29
2. Documentation of Utilization Review Notes on Acordia's System
Finding:
As part of the audit and at the request of the Auditors, Acordia analyzed the
utilization review procedures of KPHA for six large case management patients with
numerous claims. In their review, Acordia stated "Overall the utilization review
process appears consistent with industry standards. The use of the criteria to validate
admissions is documented by the precert system. Appropriate clinical documentation
was accumulated to validate the ongoing hospitalizations. Evidence of discharge
planning was also appropriately documented. Case management activity appeared on
the correct cases."
The utilization review notes are not entered on Acordia's system but had to be
researched, copied and sent to Acordia by KPHA. Clinical documentation was noted
as "sketchy" by the Nurse Reviewer on one case. On another case she stated "One
admission had minimal documentation included, however, medical records had been
attached which validated the appropriateness of the stay. KPHA has the capability to
enter the notes directly into Acordia's system. Acordia's procedures require large
physician bills and hospital bills to be referred to the Cost Containment Unit for
review and if these KPHA clinical notes were in the system the Nurses and Claims
Examiners would have all pertinent information to make decisions on the claim.
Recommendation(s):
1. KPHA should enter clinical documentation directly into Acordia's claim system.
County Administrator's Response:
Management will require KPHA to enter their review notes directly into Acordia's
system.
30
3. Outside Audits For Large Hospitalizations
Finding:
According to Interisk Management, it is customary within the industry for large
hospital bills to be referred to outside vendors that carefully analyze the charges that
could include an in-hospital review of the patients records to ensure all charges were
for services rendered. Acordia Management indicated it was their belief that
referring a claim for outside audit was normally not cost effective. The County may
want to verify this opinion by selecting a future claim and referring it to an outside
vendor for a detailed audit. One recent hospital stay was billed at $250,000 and was
not reviewed by KPHA Large Case Management. The savings on one large hospital
bill could more than pay for the cost of the service and often the fee is based on a
percentage of the savings. The procedure can be coordinated with KPHA and
Acordia.
Recommendation(s):
1. Group Insurance Management should review the concept of audits of large
hospital bills.
County Administrator's Response:
This service is provided by Acordia. Their Cost Containment Staff reviews every
inpatient billing exceeding $10,000 in an out-of-network facility and every billing
exceeding $40,000 in a network facility. The email describing their service is
attached.
31
•
H. Employee Benefit Plan Document dated October 1, 1996
Finding:
The Monroe County Health Benefit Plan Document is dated October 1, 1996. Many
changes to the plan have been made since 1996. According to Acordia Management
they use e-mail documentation of many of the changes made to the plan. There have
been three formal written amendments to the Employee Benefits Plan Document.
These amendments are given to the employees and they are told to attach the
amendments to their plan document for future use. Claims Examiners and employees
refer to this document for information on the plan. Acordia Management further
states that ERISA requires the plan document be updated every 5 years, however,
even though Monroe County is an exempt governmental unit it would be beneficial to
Acordia when processing the claims if it was revised.
Recommendation(s):
1. Group Insurance Management should consider revising the Health Benefit Plan
Document.
County Administrator's Response:
Group Insurance Management is in the process of revising the Plan Document and it
will be reissued as soon as possible, but certainly within the first quarter of 2004.
Plan changes adopted by the Board of County Commissioners during April 2003 will
be incorporated.
32
I. Payment Method Employed For Surgical Procedures
Finding:
Group Insurance stated that payment for surgical procedures should be calculated
according to Medicare's Multiple Surgery Guidelines and was under the assumption
that Acordia was using this method. Using Medicare's guidelines a second surgical
procedure performed during an operation is reduced to 50%. Acordia's method of
payment of surgical procedures is to reduce the second procedure to 50% if it is not
performed through the same incision as the primary procedure. One second surgical
procedure, CPT Code 36533 was paid at 100% or $1,200 as processed according to
Acordia's same incision policy. If it was processed according to Medicare's
Guidelines, the County would have paid $600 for this second procedure. Acordia
Management states there are very few operations where there is a second incision
required. Acordia Management further states it would be easier to process the claims
according to Medicare's Guidelines, however, if the network does not agree to using
Medicare's Guidelines the patient could be billed for any differences.
Recommendation(s):
1. Group Insurance Management should discuss the consequences of using
Medicare's Multiple Surgery Guidelines with KPHA.
2. Group Insurance Management should also consider including an acknowledgment
form to be signed by Acordia Management that states the change has been made
and the date it was implemented.
County Administrator's Response:
The proposal to use Medicare guidelines was suggested by KPHA management.
There will be further discussions of the consequences with them. Management will
incorporate an acknowledgment with all future changes.
33
J. Chiropractic and Massage Therapy Visits
Finding:
Chiropractic and Massage Therapy visits totaled $15,236 for the audit test period and
represents 5% of the total test amount. KPHA has recommended and the County has
implemented a limitation of chiropractic visits of 30 per year and massage therapy to
15 visits per year. Most physician bills reviewed for the audit test period were billed
with three to six procedure codes per visit. Internal audit was not able to review the
physician bills. Group Insurance Management might want to consider having KPHA
review the chiropractic and massage therapy billing to see if further oversight is
necessary, such as pre-certification or additional limits on the benefits.
Recommendation(s):
1. Group Insurance should coordinate the analysis of massage therapy and
chiropractic visits with KPHA.
County Administrator's Response:
In plan changes adopted April 17, 2003 by the Board of County Commissioners,
Massage Therapy was eliminated and Chiropractic Visits were limited to 15.
34
VI. EXHIBITS
Exhibit A
Administrative Service Agreement
ADMINISTRATIVE SERVICE AGREEMENT
S —
THIS AGREEMENT, made and entered into the / day of
(WIR--1064D._ by and between Monroe County (hereinafter called "Employer")
and ACORDIA NATIONAL of 602 Virginia Street, East, Charleston, WV 25301, is
hereinafter set forth:
WITNESSETH
WHEREAS, Employer has established an employee welfare benefit plan
(hereinafter called "Plan") for the purpose of providing medical, dental, vision,utilization
review, Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), Health
Insurance Portability and Accpuntability Act of 1996 ("HIPAA"), and other benefits for
its employees;
WHEREAS, Employer desires to engage the services of Acordia National
as agent for the Employer for the purpose of effecting claim administration under its
Plan; and
NOW, THEREFORE, in consideration of the mutual covenants and
promises hereinafter contained, the parties hereto agree as follows:
1) The effective date of the Employer's Plan shall be October 1.
2) The Plan Year shall be from October 1 thru September 30 of each
year.
3) The Employer's Tax Identification Number is 596000749
4) For each Plan Year, the Employer shall provide monies sufficient
to pay benefits under the Employer's Plan on a timely basis. "Timely"
shall be defined as within thirty(30) days of Acordia National's
notification, oral or written, that benefit claims have been processed for
payment. In the event Employer shall fail to provide sufficient monies to
fund its claims in a timely manner, a ten percent (10%) surcharge shall be
added to the monthly administrative fee due Acordia National,which
surcharge shall become chargeable beginning on the thirty-first(31st) day
after Acordia National's notification, as described herein. Employer
acknowledges and agrees that Acordia National shall not have any
financial duty or responsibility to release claim payments if Employer has
not sufficiently funded the same.
5) Employkr acknowledges and agrees that Acordia National shall not
have any financial duty or responsibility to see that the Employer deposit
meets the Employer's Plan requirements; however, Acordia National shall
keep the Employer advised as to the amount of deposit needed to meet
said requirements on a timely basis. Employer further acknowledges and
agrees that Acordia National shall not be deemed a fiduciary for the Plan
within the meaning of the Employee Retirement Income Security Act of,
1974 ("ERISA"). Accordingly, the services to be performed by Acordia
National hereunder shall be limited to the ministerial services set forth
herein and the performance by Acordia National shall be subject in all
respects to review by Employer within the framework of Plan provisions
as well as polices, interpretations, rules, practices and procedures
established by Employer. Acordia National shall not have any
2 -•
discretionary authority or control with regard to the management of Plan
assets. To the extent permitted by law, Acordia National shall not incur
any liability for any acts or for failure to act except for its own willful
misconduct in administering the Plan.
6) The monthly capitation fee for administrative services will be:
October 1, 2002
Medical Claims Administration $10.19 PEPM*
Dental Claims Administration $ 1.80 PEPM*
Vision Claims Administration $ 0.41 PEPM*
Pre-certification Administration PERFORMED BY KPHA
HIPAA Administratio $ 0.40 PEPM*
• Per Employee, Per Month
The above monthly capitation fee shall apply to renewal effective October 1,
2002, and will remain the same for renewals effective October 1, 2003 and October 1,
2004.
Payment of the fees established above is due from the Employer on or before the
10th day of each month, beginning on the 10th day of October, 2002. The fee quoted is
three (3) year guarantee effective October 1, 2002. The cost of any additional services
rendered by Acordia National on behalf of the Employer necessitated by a change in
federal or state law will also be charged to the Employer in addition to the monthly fee.
Employee counts for purposes of monthly administrative fee billing may not be reduced
by more than 10% of the billed enrollment unless an explanation is provided.
Administrative fee adjustments must be done monthly and cannot be adjusted
3
retroactively in excess of 90 days prior to the month invoiced. Acordia National reserves
the right to withhold any fees due to the client if administrative fees are outstanding.
Acordia National shall provide generic enrollment forms, claim forms and other
administrative and plan forms. In the event Employer desires customized administrative
and plan forms,Acordia National will direct the printing of same, however, the cost of
such printing shall be paid solely by the Employer.
, 7) Acordia National shall provide the following services in connection with
the administration of Employer's Plan(s):
a) Provide assistance to enroll all eligible Employees (as
defined in the Employer's Plan) in Employer's Plan, as agreed
with Enaployer;
b) Design and obtain other coordinating or supplemental types
of insurance coverage, where necessary, as requested by Employer
in writing;
c) Assist and advise employer in revising Plan Document.
Provide prototype Plan Documents and Identification Cards (ID
Cards) for the Employer. Arrange for printing and preparation of
such documents. The cost of the printing will be the responsibility
of the Employer;
d) Conduct information programs for all eligible Employees
to fully explain the benefits available under the Employer's Plan,
as requested by Employer;
4 _.
e) Respond to telephone and mail inquiries from Plan
participants regarding benefits available to them and their
dependents.
f) Provide information concerning Plan benefits and
participants, based upon information provided by Employer;
g) Review and analyze all claims and determine whether the
charges of health care providers submitted are within reasonable
payment guidelines and/or are related to diagnostic related groups,
preferred provider organization agreements or other industry
standards;
h) Rorrespond with claimants, as necessary, to prove claims
and to ascertain whether other coverage exists which might pay the
claim in whole or part;
i) Receive, review, and administer all claims for benefits
under the Employer's Plan, including the evaluation of claims
made; standard evaluation of the eligibility status of all claimants,
coordination of and at least annual auditing of the Utilization
Review and Case Management function, provide the County with
results of Utilization Review audit, appropriate Coordination of
Benefits evaluation of all claims, supply data to Health Recoveries,
Inc. necessary for subrogation and other functions usual to the
efficient and cost effective administration of claims;
5 -
OUT-OF COUNTY PROVIDERS. KPHA agrees to negotiate and contract with
"Dimension Network" in Dade, Broward and Palm Beach Counties for discounted fee
arrangements with physicians, hospitals, and other ancillary health services as needed for the
benefit of the Employer. If the "Dimension Network" is not utilized, or becomes unacceptable to
the Employer, KPHA will propose other alternative arrangements for such out of county
services.
3. UTILIZATION MANAGEMENT AND QUALITY ASSURANCE. KPHA shall
provide for Employer Utilization Review services to include
• Review of inpatient admissions and of continued hospital stay
• Discharge planning
• Data collection and reporting
• Review of supportive or treatment services
• Review of office visits, ambulatory surgery and diagnostic or other outpatient
services
• Review of billing practices and appropriateness of charges of network providers
• Large Case Management services
The monthly capitation fee for such services will be$1.35 per employee per month. This fee will
be payable by the County to KPHA by the 20th of each month beginning on the 20th day of
October, 2002. The number of enrollees will be determined on the 1st business day of each
month.
KPHA shall provide for Large Case Management services for a fee of$55.00 per hour on an as-
needed basis. Large Case Management services may be pre-approved by the County on a case by
case basis and billings for such fees incurred shall be provided monthly with details of all
charges.
Utilization Review and Large Case Management services will be performed according to pre-set
protocols developed in conjunction with the claims administrators(Acordia National's) standards
and will be documented in the claims administrators' computer system.
4. WELLNESS PROGRAMS AND OTHER EDUCATIONAL SERVICES. KPHA
shall design and implement with the coordination of Employer's staff, the Worksite Wellness
Program and other similar services to the Employer and Covered Persons to promote healthy
lifestyles and preventative health care. The Worksite Wellness Program will include, at no
additional charge to Employer or Covered Persons, a health risk assessment for each employee
and may include, for a charge by a Participating Provider, Health Physical Packages. Health Fair
coordination and implementation or other services as negotiated and deemed to promote healthy
lifestyles and preventative health care may also be included in this service.
Page 2
5. PARTICIPATING PROVIDER COMPENSATION. Employer shall compensate
Participating Providers for covered services minus any plan participant responsibilities.
Employer has the responsibility for implementation of the applicable claims pay
ment submitted
by Participating Providers for services rendered or for any billing or other function related to the
health care services provided by Participating Providers to Covered Persons. All claims for
covered services, whether payable by the Employer or a Covered Person will receive a discount
off of provider billed charges as specified in Attachment A. This discount will be rescinded if
an appropriately documented and non-contested claim is not paid to the Participating Provider
within thirty(30) days of being received by the claims administrator(Acordia National).
NON-APPROPRIATIONS. CLAUSE. Monroe County's performance and obligation
to pay under this contract is contingent upon an annual appropriation by the BOCC. Monroe
County may not deny payment for valid and accurate claims properly submitted and rendered
during the plan year.
PROVIDER REIMBURSEMENT TERMS. KPHA shall use best efforts to ensure that
the Participating Provider's physician Usual Customary and Reasonable (UCR) charges will not
change during the term of one year. Thereafter, KPHA agrees to provide a ninety (90) day
notification in the event of a charge increase. Physician UCR charges will be based upon "the
Medicode database." The above agreed upon discount will be applied to the billed charge, not to
exceed the UCR charge for a service.
KPHA further agrees that no other self-insured employer contracting with KPHA will be
provided with better overall terms than what is being here agreed. If however, better terms are
provided to another self-insured employer contracting with KPHA, such terms will also be
extended to the Employer.
6. COVERED PERSON IDENTIFICATION. Employer shall supply Covered Persons
with identification cards or other means of identification which clearly identifies KPHA, reflects
the Covered Person's coverage under the applicable Employers health benefit plan, and reflects
the Covered Person's eligibility to receive services from Participating Providers in accordance
with the terms of this Agreement. Employer shall also provide such other services as may be
required in order for Participating Providers promptly to verify the status of individuals as
Covered Persons, the terms of the Covered Person's health care benefits, including but not
limited to the applicable terms of-coverage, deductible status and co-insurance.
7. NETWORK EXCLUSIVITY. During the course of the agreement Employer agrees not
to participate or enter agreements to utilize other provider networks other than that agreed upon
with KPHA and the Employer. Employer during the term of this Agreement shall not seek to
negotiate with individual network members for care or services outside of contractual provisions
without prior notification to KPHA.
Page 3
-
I
8. BOOKS AND RECORDS. KPHA shall make available to claims administrator
(Acordia National) all records and other data relating to both the network and utilization review
and case management services for the purpose of periodic audits of KPHA's services.
Information/data will be maintained, as required, to assure confidentiality and compliance with
all applicable regulations.
9. RESPONSIBILITY FOR HEALTH CARE SERVICES. Employer agrees that KPHA
shall not have any responsibility or liability for any act, omission,.or decision related to medical
services rendered by Participating Providers to a Covered Person.
10. TERM. This Agreement shall continue in effect for one (:1) year from the date first
above written. Thereafter,the Agreement shall renew for two(2)consecutive one (1)year terms.
KPHA agrees to provide the Employer with at least ninety (90) days written notice of the intent
to terminate, non-renew, or amend this Agreement. The Employer agrees to provide KPHA with
at least ninety (90) days written notice of the intent to terminate or non-renew this agreement.
Any modification of the terms of this agreement may occur upon the mutual'agreement of the
parties.
BREACH AND CURE. Notwithstanding the foregoing, this Agreement may be
terminated by either party upon a material breach of this Agreement by the other party,providing
that the breaching party does not cure the breach within thirty.(30) days following receipt of a
written notice from the non-breaching party specifying the nature of the breach and requesting
that it be cured.
11. GENERAL PROVISIONS.
A. THIRD PARTIES: The terms and provisions of this Agreement are for the
benefit of the parties hereto and are not intended to provide any other person with any right or
cause of action on account thereof.
B. NOTICES: Any notice required to be given pursuant to the terms and provisions
thereof shall be in writing and shall be hand-delivered, with return receipt thereof, or sent by
certified or registered mail, return receipt requested and first-class postage prepaid to the
addresses as follows:
Employer: County of Monroe
Manager-Employee Benefits
Public Service.Building
5100 College Road, Stock Island
Key West, Fl 33040
Page 4
KPHA: Keys Physician-Hospital Alliance
c/o Lower Florida Keys Physician Hospital Organization,.Inc.
P.O. Box 9107
Key West, Florida 33041-9107
Attn.: Ronald Bierman, Secretary
C. ASSIGNMENT: This Agreement may not be assigned, subcontracted,
delegated, transferred by either party without the express written consent of the other party, and
any attempted assignment, subcontract, delegation or transfer shall be void.
D. INDEPENDENT CONTRACTORS: None of the provisions of this Agreement
are intended to create, nor shall be deemed to, or construed to create any relationship between
KPHA and Employer other than that of independent entities contracting with each other
hereunder solely for the purposes of effecting the provisions of this Agreement. Neither of the
parties hereto, nor any of their respective officers, directors, or employees shall be construed to
be the agent, employee, or representative of the other.
E. GOVERNING LAW: This Agreement shall be governed in all respects by the
laws of the State of Florida without regard to Florida's choice of law statutes or decisions. Any
action by any party, whether at law or in equity, relating to this Agreement shall be commenced
and maintained, and venue shall be proper,only in Monroe County, Florida.
F. ORDINANCE 10-1990: KPHA warrants that it has not employed, retained or
otherwise had acted on his behalf any former County officer subject to the prohibition in Sec. 2
of Ordinance no. 10-1990 or any County officer or employee in violation of sec. 3 of Ordinance
10-1990, and that no employee or officer of the County had any interest, financially or otherwise,
in KPHA except for such interest, permissible by law and fully disclosed by affidavit attached
hereto. For breach or violation of this paragraph, the County may, in its discretion,terminate this
agreement without liability and may also, in its discretion, deduct from the contract or purchase
price, or otherwise recover, the full amount of any fee, commission, percentage, gift or
consideration paid to the former County officer or employee.
G. CONFLICT OF INTEREST: KPHA assures the County that to the best of its
knowledge information and belief, the signing of this agreement does not create conflict of
interest.
Page 5
irf
•
H. OWNERSHIP OF INFORMATION: All Utilization Review and Case
Management documents which are prepared in the performance of this agreement are to be, and
shall remain, the property of the County and shall be transferred to the County or to a
replacement Utilization Review/Case Management service provider upon request and no later
than thirty (30) days after termination of this agreement. Any patient identifying information
shall not be disclosed without written consent of the patient.
I. INSURANCE REQUIREMENTS: KPHA is required to maintain the types of
insurance identified in Attachment B.
J. SEVERABILITY: If any provision of this Agreement is held to be illegal,
invalid, or unenforceable, under present or future laws effective during the term hereof, such
provision shall be fully severable. In such event, this Agreement shall be construed and enforced
as if the illegal invalid or unenforceable provision had never been a part hereof', and the
remaining provisions shall remain in full force and effect unaffected by such severance-provided
that if the illegal, invalid or unenforceable provision is material to the overall purpose..and
operation of this Agreement, then this Agreement shall terminate upon the severance of such
provision.
K. COUNTERPARTS: This Agreement and any amendment hereto may be
executed in multiple originals, all counterparts together constituting one and the same
instrument.
L. ENTIRE AGREEMENT: This Agreement, along with its exhibits, contains all
the terms and conditions agreed upon by the parties hereto regarding the subject matter of this
Agreement and supersedes any prior Agreements, promises, negotiations, or representations
either oral or written,relating to the subject matter of this Agreement.
M. HOLD HARMLESS: KPHA shall indemnify and hold the County harmless
from and against any and all losses, penalties, damages,professional fees, including attorney fees
and all costs of litigation and/or judgment arising out of any willful misconduct or negligent act,
error or omission of KPHA incidental to the performance of this agreement or work performed
thereunder. This indemnity shall extend to amounts the County becomes legally obligated,to pay
and shall be limited by any sovereign immunity limit applicable to the underlying claim plus
costs of litigation.
In witness wherof; the Employer and KPHA have caused this Agreement to be executed by their
respective corporate officers, effective as of the first day of October 2002.
Page 6
•
Employer: Board of Co Commissioners
of Monroe .Florida
By: (CAa /e s .�on4y'/ncCe,/
Its: /t�a)/ Clairryrlah 9/8-4>-
Keys Physician-Hospital Allianc
By:
Its: Pres idev
"all 8
if ,4\
w f
A S:DANNY L E
DEPUTYCLERK
APPROVED AS TO F
AND L SUFF I CY
ZANg7/HUTTON
DATE J- d
APPROV ASSUFFICI TO FO
AND AL
BY NNE
ATE D �L
Page 7
Attachment A
• Reimbursement Schedule
KPHA Members 85% of billed charges with the cap of the 90th percentile of the Medicode
Fee Schedule.
In County Providers(IPN) 85% of billed charges with the cap of the 906 percentile of the Medicode
Fee Schedule.
Out-of-County Providers(IPN) 70% of billed charges with the cap of the 90th percentile of the Medicode
Fee Schedule.
Dimension Providers Dimension Network Fee Schedule
Fisherman's Hospital 75% of billed charges.
•
Lower Keys Medical Center 75% of billed charges.
A list of specific providers and discount percentages will be provided to Acordia National by KPHA for
implementation.
//
James Roberts,County Admir7a Date
of 1
Stephen Krathen,D.O. Date
KPHA President
•
I 1
I ..
1996 Edition
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION
MANUAL
General Insurance Requirements
for
Other Contractors and Subcontractors
As a re-re p quisite of the work governed,or the goods supplied under this contract(including the
pre-staging of personnel and material),the Contractor shall obtain, at his/her own expense,
insurance as specified in any attached schedules,which are made part of this contract. The
Contractor will ensure that the insurance obtained will extend protection to all Subcontractors
engaged by the Contractor. As an alternative,the Contractor may require all Subcontractors to
obtain insurance consistent with the attached schedules.
The Contractor will not be permitted to commence work governed by this contract(including
i pre-staging of personnel and material)until satisfactory evidence of the required insurance has
been furnished to the County as specified below. Delays in the commencement of work,
resulting from the failure of the Contractor to provide satisfactory evidence of the required
insurance, shall not extend deadlines specified in this contract and any penalties and failure to
perform assessments shall be imposed as if the work commenced on the specified date and time,
except for the Contractor's failure to provide satisfactory evidence.
The Contractor shall maintain the required insurance throughout the entire term of this contract
and any extensions specified in the attached schedules. Failure to comply with this provision
may result in the immediate suspension of all work until the required insurance has been
reinstated or replaced. Delays in the completion of work resulting from the failure of the
Contractor to maintain the required insurance shall not extend deadlines specified in this contract
and any penalties and failure to perform assessments shall be imposed as if the work had not •
been suspended, except for the Contractor's failure to maintain the required insurance.
The Contractor shall provide, to the County,as satisfactory evidence of the required insurance,
either:
• Certificate of Insurance •
or
• A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a certified copy of any or all insurance
policies required by this contract.
All insurance policies must specify that they are not subject to cancellation,non-renewal,
material change, or reduction in coverage unless a minimum of thirty (30) days prior notification
is given to the County by the insurer.
The acceptance and/or approval of the Contractor's insurance shall not be construed as relieving
the Contractor from any liability or obligation assumed under this contract or imposed by law.
Administration Instruction
#4709.3 14
1996 Edition
The Monroe County Board of County Commissioners, its employees and officials will be
included as "Additional Insured" on all policies, except for Workers'Compensation.
Any deviations.from these General Insurance Requirements must be requested in writing on the
County prepared form entitled "Request for Waiver of Insurance Requirements" and
approved by Monroe County Risk Management.
•
•
•
' I
I y
I I
I I
Administration Instruction
15
#4709.3
Ij
•
1996 Edition
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY,FLORIDA
AND
Keys Physician-Hospital Alliance
Prior to the commencement of work governed by this contract,-the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract
and include, as a minimum:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Injury Liability
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$500,000 Combined Single Limit(CSL)
If split limits are provided,the minimum limits acceptable shall be:
$250,000 per Person •
$500,000 per Occurrence
$ 50,000 Property Damage •
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition,the period for which claims may be reported should extend for a minimum of twelve
(12)months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
GL2
Administration Instruction
#4709.3 55
1996 Edition
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY,FLORIDA
AND
Keys Physician-Hospital.Alliance
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers'Compensation Insurance with limits sufficient to respond to Florida Statute 440.
In addition,the Contractor shall obtain Employers'Liability Insurance with limits of not less
than:
$100,000 Bodily Injury by Accident
_ $500,000 Bodily Injury by Disease,policy limits
$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
If the Contractor has been approved by the Florida's Department of Labor, as an authorized self-
insurer,the County shall recognize and honor the Contractor's status. The Contractor may be
required to submit a Letter of Authorization issued by the Department of Labor and a Certificate
of Insurance,providing details on the Contractor's Excess Insurance Program,
If the Contractor participates in a self-insurance fund,a Certificate of Insurance will be required.
In addition,the Contractor may be required to submit updated financial statements from the fund
upon request from the County.
WC1
Administration Instruction
#4709.3 88
I ?
1996 Edition
PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY,FLORIDA
AND
Keys Physician-Hospital Alliance
Recognizing that the work governed by this contract involves the furnishing of advice or services
of a professional nature,the Contractor shall purchase and maintain,throughout the life of the
contract,Professional Liability Insurance which will respond to damages resulting from any
claim arising out of the performance of professional services or any error or omission of the
Contractor arising out of work governed by this contract.
The minimum limits of liability shall be:
$500,000 per Occurrence/$1,000,000 Aggregate
•
PRO2
Administration Instruction
78
#4709.3
1996 Editioa
VEHICLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY,FLORIDA
AND
Keys Physician-Hospital Alliance
Recognizing that the work governed by this contract requires the use of vehicles,the Contractor,
prior to the commencement of work, shall obtain Vehicle Liability Insurance. Coverage shall be
maintained throughout the life of the contract and include, as a minimum,liability coverage for:
• Owned,Non-Owned, and Hired Vehicles
•
The minimum limits acceptable shall be:
$300;000 Combined Single Limit(CSL)
If split limits are provided,the minimum limits.acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
VL2
Administration Instruction
#4709.3 82
1996 Edition
EMPLOYEE DISHONESTY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY,FLORIDA
AND
Keys Physician-Hospital Alliance
The Contractor shall purchase and maintain, throughout the term of the contract,Employee
Dishonesty Insurance which will pay for losses to County property or money caused by the
fraudulent or dishonest acts of the Contractor's employees or its agents,whether acting alone or
in collusion of others.
The minimum limits shall be:
$10,000 per Occurrence
EDI
Administration Instruction
45
#4709.3
PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who has been placed on the convicted vendor list
following a conviction for public entity crime may not submit a bid on a
contract to provide any goods or services to a public entity, may not submit
a bid on a contract with a public entity for the construction or repair of a
public building or public work, may not submit bids on leases of real
property to public entity, may not be awarded or perform work as a
contractor, supplier, subcontractor, or consultant under a contract with any
public entity, and may not transact business with any public entity in excess
of the threshold amount provided in Section 287.017, for CATEGORY
TWO for a period of 36 months from the date of being placed on the
convicted vendor list."
Exhibit B
Monroe County Board of Commissions Cost.
Per Employee Comparison
' Monroe County Board of Commissions
f Cost Per Employee Comparison
(1/1/01 - 12/31/01 Statistics used for Comparative Purposes)
Monroe County Monroe County
Vs.Similar Acordia National Clients Vs. Mercer/Foster Higgins National
Statistics
11-7.17
$450 ,r M ,b x ,:, y ' $500 5` _: s . `�,,..:
.7 v �4 �r , : �t� PS ...c..`f� �s6,A�soh .� i�"S,:,- a, ''�...���9r�''�
$400 1r t, fi rib ° $450 � ..,. W # q €
- $350 t M :, 3 $400 + D.s'�- ,
$300ie
11.-. ._71-...::.:1 , y , � -. $350 <.
$2500 a '}'ts' � t' $300 n
$250 1 RA
$150 0 t, o r ..f ,Ya , $200.
$150 47,4
$100 ; ,k x: , $100
$50
CO .e_ .
.. s..r-T S
. f - F' (E'Is ,' .�- _.�...,..
Client Industry Enroll. Region Client Industry Enroll. Region
"[Cost Per Employee ■Cost Per Employee
Cost Per Employee Comparison Cost Per Employee Comparison
To Similar Acordia National Clients To Mercer/Foster Higgins National Statistics
(Medical Claims Only) (Medical & RX Claims and Administrative Fees)
Client (10/01 - 9/02): $439 Client (10/01 -9/02): $450
Similar Industry (All Clients): $298 Similar Industry (All Clients): $379.
Similar Enrollment (1000-1999 EE's): $334 Similar Enrollment (1000-1999 EE's): $385
Region (South): N/A Region (South): $354
Monroe County Board of Commissions.
(10/01101 -9/30/02)
Experience By Cause Comparison (% of Total Claims Paid)
(1/1/01 - 12/31/01 Acordia National Normative Data Used for Comparative Purposes)
.WW:4YYaYYW
Monroe County I 0.28%
�w.Ymwm.mwruaWmmn�:mtlWowunnm 0.28%
0.69%
3.54% 5.43%
RYA „.
■Accident 7. r .
z
■Illness
®Maternity _ `z
C Psych ,
O Chem Dep •
O Vision
89.78%
YW:MWWWW444YYLYWWYYMNYYtlWMp:4WiWNhMYtltlYYMMYWYtl .
Similar Size(1000-1999 EE's)
0.44%
1.13% 0.04%
4.61% —4.90%
®Accident -TotiAAO, 1 f
®Illness cad -
C Maternity
O Psych ''
CI Chem Dep �' f
CI Vision �. . • �,
..1
88.88%
W laupu itmu NmuIJI 1411 W;G9!11,a P11.441111111UIflMCU]t"JI.'W:UUI:
it Similar Industry(All Clients) `{
66141661Wrt6N111W1tlll111611111MY16161111MMIN6CCI11111C111WCu661016111CCCC14=I�
0.29%
1.77% 0.11%
4.40% 4.21%
III Accident
■Illness 'i*t •
ID Maternity •
['Psych
C Chem Dep
CI Vision '
89.22%
Monroe County Board of Commissions
Cost Per Employee Comparison
Dental Claims Only
(1/1/01 - 12/31/01 Statistics Used for Comparative Purposes)
Client: Monroe County Board of
Commissions
Versus Similar Acordia National Clients
o ?'
$35 see zi
7. `•c • 7 a ,
$30 h 4
$25 {
$20 t i 5 1 "r
$5 ' t � ',11 '
Client Industry Enroll.
■Cost Per Employee
Cost Per Employee Comparison
1/01 - 12/01 Normative Data Used for Comparative Purposes
(Dental Claims)
Client (10/01 - 9/02): $31
Similar Industry (All Clients): $26
Similar Enrollment (1000-1999 EE's): $30
in
Client: Monroe County Board of Commissions
(10/1/01 -9/30/02)
•
Comparison of Statistics to Similar Acordia National Clients
1/01 - 12/01 Normative Data Used For Comparative Purposes
•
wic 444,
Inpatient Admissions/1000 Participants 125 � z
a
- 41
e 100 E , `ate ; . .,.,� `?
Client 98 1.4
75•,, ; �' ; -1
Similar Industry 67 . 9.ri 50 '' , .1 KJ
,1
Similar Enrollment 69 0' '�r - �'•d �s ',- ' '`
Client Industry Enroll.
■Admits/1000 Part.
< k'%M.s.Scrf`b'} p;;,,,,, CSC.f+ -
Inpatient Days/1000 Participants soo ;
400 ;. 4 q v 3 Y
Client 591 300 O. . -1 ,i
Similar Industry 263 G 200 d
1 V 1 1
Similar Enrollment 274 1 0 k .L. A .... '
Client Industry Enroll.
IN Days/1000 Part.
I
Average Length of Stay7.00 AP Pdy3 �
5.00 ai,. r r-
Client 6.04 A 4.00 r - 1' ..
2 3.00 ,f Vie..
Similar Industry 3.94 2.00 i
too Similar Enrollment 3.94 0.00 d- 1
Client Industry Enroll.
•Average Length of Stay
Similar Industry: All Clients
Similar Enrollment: 1000 - 1999 Employees
1
. Percent Of Medical Claims By Disease Category
Normative Comparison of All clients of Acordia National to Monroe County Board of Commission
10/01/01 -9/30/02
Inpatient Outpatient Combined
Norm Client Norm Client Norm Client
Diseases of the nervous system 1.2% 1.2% 1.8% 1.8% 1.7% 1.5%
Diseases of the eye 0.1% 0.0% 1.6% 3.8% 1.3% 2.1%
Diseases of ear, nose,throat 0.1% 0.2% 1.5% 0.6% 1.2% 0.4%
Diseases of the respiratory system 7.1% 8.6% 5.5% 5.5% 5.8% 6.9%
Diseases of the circulatory system '1'.67°0 2,60 4.9% 6.9% 9%Q 18.7%
Diseases of the digestive system 6.6% 5.5% 4.3% 5.5% 4.8% 5.5%
Other digestive: liver, pancreas,gallbladder 4.6% 3.8% 2.2% 1.3% 2.7% 2.4%
Musculoskeletal system 6.8% 8.8% 10.4%, 17. '% 9.6°0 13.5%
Skin subcutaneous tissue breast 0.9% 1.2% 2.4% 2.5% 2.0% 1.9%
Endocrine nutritional metabolic 2.4%. 1.4% 2.6% 2.9% 2.5% 2.2%
Kidney&urinary tract 1.9% 3.4% 4.1% 7.4% 3.6% 5.5%
Male reproductive system 0.1% 0.0% 0.4% 0.4% 0.4% 0.2%
Female reproductive system 4.0% 2.5% 3.5% 2.9% 3.6% 2.7%
Pregnancy childbirth puerperium 1' ,1% 6.8% 2.0% 1.1% 3.9% 3.5%
Newborns&newborns perinatal period 6.5% 7.2% 0.8% 0.3% 2.1% 3.5%
Blood &blood forming organs 0.6% 0.8% 0.6% 0.4% 0.6% 0.6%
Meloproliferative diseases 8 3% O,%o 7.8% 7.9% 7.9% 6.1%
Infectious/parasitic diseases 1.3% 0.1% 1.0% 1.3% 1.0% 0.8%
- Mental diseases and disorders 2.5% 0.2% 1:6% 1.0% 1.8% 0.7%
Substance abuse 0.7% 0.5% 0.2% 0.1% 0.3% 0.2%
Injury&poisoning 4.3% 3.0% 5`,9% 9.6% 5.6% 6.6%
Burns 0.1% 0.0% 0.0% 0.0% 0.1% 0.0%
Factors influencing health status&well care 2.2% 2.8% 5.4% 5.2% 4.7% 4.1%
Symptoms,signs, &ill defined conditions 5.5% 5.2% 11.7% 13.0% 10.4% 9.4%
Complications of surgery&medical care 2.4% 0.8% 178%. 1.1% 14.5% 1.0%
TOTAL 100.0% 100.0% 100.0% 100.0% 100.00% 100.0%
Note: The not classified category has been omitted from these statistics.
• Medical Claims By Disease Category
Monroe County Board of Commission
A comparison of your medical claims by disease category to all clients of Acordia National offers
some insight into the pattern of your medical claims that are directly related to disease categories.
This analysis indicates categories that are much higher or much lower than the same categories
for all clients of Acordia National. Highlighted in yellow are disease categories that have the
greatest variance from our 2001 normative data.
Two categories indicated a positive variance, resulting in a significant impact on your medical
claims. Inpatient claims relating to "pregnancy childbirth puerperium" and "meloproliferative
diseases" were lower than our norms. Outpatient claims relating to "complications of surgery &
medical care" were lower than our norm also. Acordia National uses code 999 when processing
vendor claims for our clients. Code 999 is classified under this disease category. Since we do not
process your prescription drug vendor claims, the variance in this category is misleading.
Four categories indicated a negative variance, resulting in a significant impact on your medical
claims. Inpatient claims relating to the "circulatory system"were higher than our norm. There
was a 36-day admission for an intracerebral hemorrhage (431) at Baptist Hospital that generated
$288,370 in paid claims. In addition, there was a 13-day admission at Baptist Hospital for an
abdominal aneurysm, ruptured (442.3) that resulted in $71,614 in paid claims. At South Miami
Hospital there was a 3-day admission for hemiplegia affecting unspecified side (438.20). This
admission resulted in$93,419 in paid claims.
Outpatient claims relating to the "musculoskeletal system"were higher than our norm. Increased
utilization of services requiring higher cost procedures caused this variance. Fifty-six percent of
the paid claims in this category were generated by rheumatoid arthritis (714.0), unspecified
internal derangement of knee (717.9), cervical spondylosis without myelopathy (721.0); myalgia
and myositis,unspecified(729.1),joint pain,lower leg(719.46), lumbosacral spondylosis without
myelopathy (721.3), muscular wasting and disuse atrophy (728.2), hallux varus (735.1), pain in
limb (729.5), bunion (727.1), displacement of cervical intervertebral disc without myelopathy
(720.0), sciatica (724.3), lumbar intervertebral disc without myelopathy (722.10), thoracic or
lumbosacral neuritis (724.4), brachial neuritis (723.4), lumbago (724.2), and cervicalgia (723.1).
Outpatient claims for"kidney and urinary tract"were higher than our norm. Chronic renal failure
(595), calculus of kidney (592.0), and calculus of ureter (592.1) generated 79% of paid claims in
this category. Outpatient claims for "injury & poisoning" were higher than our norm also. The
variance in this category was caused by 'increased utilization of occurrences in an outpatient
setting versus an inpatient setting.
An understanding of your variances from our norms can give you direction in the areas of
management you need to target. Management could encompass modifications to your current
medical plan, implementation of disease management programs, or guidance in network decisions
that would have the most impact on claims related to the disease categories listed above.
Working with your prescription drug vendor to establish the most cost-effective drugs utilized for
these categories will have a positive impact also.
Exhibit C
Employer-Provider Network and
Utilization Review and Case
Management Services Agreement
EMPLOYER-PROVIDER NETWORK
AND
UTILIZATION REVIEW AND CASE MANAGEMENT SERVICES
AGREEMENT
THIS AGREEMENT is entered into as of this first day of OCTOBER 2002 by and
between Keys Physician-Hospital Alliance ("KPHA") and the County of Monroe
("County"), hereon referred to as "Employer". _
RECITALS
WHEREAS, the KPHA has established a network of participating health care
providers, which providers, pursuant to the terms and conditions of provider agreements
with KPHA, have agreed to deliver medical services in a cost effective manner to persons
covered under the health benefit plans and policies of Employer.
•
WHEREAS, KPHA has agreed to provide utilization review and case management
services to Employer and personnel, dependents, Cobra beneficiaries and eligible retirees
covered under the health benefit plans and policies of Employer.
WHEREAS, Employer administers the health care benefit plans and has the express
authority, by signing this Agreement,to bind the Employer to all of the terms and conditions
of this Agreement.
WHEREAS,, Employer desires and agrees to offer KPHA Provider Network to
persons covered under the Employers health benefits plans;
Now, THEREFORE, the parties agree as follows:
1. RECITALS. The foregoing recitals are hereby incorporated by reference and
made a substantive part hereof
2. LIST OF PARTICIPATING PROVIDERS. KPHA shall provide Employer
with a list of Participating Providers, to include hospitals, physicians, dentists, pharmacies,
and other ancillary health services, and shall provide Employer with periodic updates of the
Network roster of Participating Providers from time to time. Such updates will be at least
semi-annually and in such a printed format as distributable to persons covered under the
Employers health benefits plans.
Page 1
OUT-OF COUNTY PROVIDERS. KPHA agrees to negotiate and contract with
"Dimension Network" in Dade, Broward and Palm Beach Counties for discounted fee
arrangements with physicians, hospitals, and other ancillary health services as needed for the
benefit of the Employer. If the "Dimension Network" is not utilized, or becomes unacceptable to
the Employer, KPHA will propose other alternative arrangements for such out of county
services.
3. UTILIZATION MANAGEMENT AND QUALITY ASSURANCE. KPHA shall
provide for Employer Utilization Review services to include
• Review of inpatient admissions and of continued hospital stay
• Discharge planning
• Data collection and reporting
• Review of supportive or treatment services
• Review of office visits, ambulatory surgery and diagnostic or other outpatient
services
• Review of billing practices and appropriateness of charges of network providers
• Large Case Management services
The monthly capitation fee for such services will be$1.35 per employee per month. This fee will
be payable by the County to KPHA by the 20th of each month beginning on the 20th day of
October, 2002. The number of enrollees will be determined on the 1st business day of each
month. -
KPHA shall provide for Large Case Management services for a.fee of$55.00 per hour on an as-
needed basis. Large Case Management services may be pre-approved by the County on a case by
case basis and billings for such fees incurred shall be provided monthly with details of all
charges.
Utilization Review and Large Case Management services will be performed according to pre-set
protocols developed in conjunction with the claims administrators (Acordia National's) standards
and will be documented in the claims administrators' computer system.
4. WELLNESS PROGRAMS AND OTHER EDUCATIONAL SERVICES. KPHA
shall design and implement with the coordination of Employer's staff, the Worksite Wellness
Program and other similar services to the Employer and Covered Persons to promote healthy
lifestyles and preventative health care. The Worksite Wellness Program will include, at no
additional charge to Employer or Covered Persons, a health risk assessment for each employee
and may include, for a charge by a Participating Provider, Health Physical Packages. Health Fair
coordination and implementation or other services as negotiated and deemed to promote healthy
lifestyles and preventative health care may also be included in this service.
Page 2
5. PARTICIPATING PROVIDER COMPENSATION. Employer shall compensate
Participating Providers for covered services minus any plan participant responsibilities.
Employer has the responsibility for implementation of the applicable claims payment submitted
by Participating Providers for services rendered or for any billing or other function related to the
health care services provided by Participating Providers to Covered Persons. All claims for
covered services, whether payable by the Employer or a Covered Person will receive a discount
off of provider billed charges as specified in Attachment A. This discount will be rescinded if
an appropriately documented and non-contested claim is not paid to the Participating Provider
within thirty(30) days of being received by the claims administrator(Acordia National).-
NON-APPROPRIATIONS CLAUSE. Monroe County's performance and obligation
to pay under this contract is contingent upon an annual appropriation by the BOCC. Monroe
County may not deny payment for valid and accurate claims properly submitted and rendered
during the plan year.
PROVIDER REIMBURSEMENT TERMS. KPHA shall use best efforts to ensure that
the Participating Provider's physician Usual Customary and Reasonable (UCR) charges will not
change during the term of one year. Thereafter, KPHA agrees to provide a ninety (90) day
notification in the event of a charge increase. Physician UCR charges will be based upon "the
Medicode database." The above agreed upon discount will be applied to the billed charge, not to
exceed the UCR charge for a service.
KPHA further agrees that no other self-insured employer contracting with KPHA will be
provided with better overall terms than what is being here agreed. If however, better terms are
provided to another self-insured employer contracting with KPHA, such terms will also be
extended to the Employer.
6. COVERED PERSON IDENTIFICATION. Employer shall supply Covered Persons
with identification cards or other means of identification which clearly identifies KPHA, reflects
the Covered Person's coverage under the applicable Employers health benefit plan, and reflects
the Covered Person's eligibility to receive services from Participating Providers in accordance
with the terms of this Agreement. Employer shall also provide such other services as may be
required in order for Participating Providers promptly to verify the status of individuals as
Covered Persons, the terms of the Covered Person's health care benefits, including but not
limited to the applicable terms of coverage, deductible status and co-insurance.
7. NETWORK EXCLUSIVITY. During the course of the agreement Employer agrees not
to participate or enter agreements to utilize other provider networks other than that agreed upon
with KPHA and the Employer. Employer during the term of this Agreement shall not seek to
negotiate with individual network members for care or services outside of contractual provisions
without prior notification to KPHA.
Page 3
8. BOOKS AND RECORDS. KPHA shall make available to claims administrator
(Acordia National) all records and other data relating to both the network and utilization review
and case management services for the purpose of periodic audits of KPHA's services.
Information/data will be maintained, as required, to assure confidentiality and compliance with
all applicable regulations.
9. RESPONSIBILITY FOR HEALTH CARE SERVICES. Employer agrees that KPHA
shall not have any responsibility or liability for any act, omission, or decision related to medical
services rendered by Participating Providers to a Covered Person.
10. TERM. This Agreement shall continue in effect for one (.1) year from the date first
-.' above written. Thereafter,the Agreement shall renew for two (2)consecutive one (1)year terms.
KPHA agrees to provide the Employer with at least ninety (90) days written notice of the intent
to terminate, non-renew, or amend this Agreement. The Employer agrees to provide KPHA with
at least ninety (90) days written notice of the intent to terminate or non-renew this agreement.
Any modification of the terms of this agreement may occur upon the mutual'agreement of the
parties. -
BREACH AND CURE. Notwithstanding the foregoing, this Agreement may be
terminated by either party upon a material breach of this Agreement by the other party,providing
that the breaching party does not cure the breach within thirty (30) days following receipt of a
written notice from the non-breaching party specifying the nature of the breach and requesting
that it be cured.
11. GENERAL PROVISIONS.
A. THIRD PARTIES: The.terms and provisions of this Agreement are for the
benefit of the parties hereto and are not intended to provide any other person with any right or
cause of action on account thereof.
B. NOTICES: Any notice required to be given pursuant to the terms and provisions
thereof shall be in writing and shall be hand-delivered, with return receipt thereof, or sent by
certified or registered mail, return receipt requested and first-class postage prepaid to the
addresses as follows:
Employer: County of Monroe
Manager-Employee Benefits
Public Service Building
5100 College Road, Stock Island
Key West, Fl 33040
Page 4
KPHA: Keys Physician-Hospital Alliance
do Lower Florida Keys Physician Hospital Organization, Inc.
P.O. Box 9107
Key West, Florida 33041-9107
Attn.: Ronald Bierman, Secretary
C. ASSIGNMENT: This Agreement may not be assigned, subcontracted,
delegated, transferred by either party without the express written consent of the other party, and
any attempted assignment, subcontract, delegation or transfer shall be void.
D. INDEPENDENT CONTRACTORS: None of the provisions of this Agreement
are intended to create, nor shall be deemed to, or construed to create any relationship between
KPHA and Employer other than that of independent entities contracting with each other
hereunder solely for the purposes of effecting the provisions of this Agreement. Neither of the
parties hereto, nor any of their respective officers, directors, or employees shall be construed to
be the agent, employee, or representative of the other.
E. GOVERNING LAW: This Agreement shall be governed in all respects by the
laws of the State of Florida without regard to Florida's choice of law statutes or decisions. Any
action by any party, whether at law or in equity, relating to this Agreement shall be commenced
and maintained, and venue shall be proper,only in Monroe County, Florida.
F. ORDINANCE 10-1990: KPHA warrants that it has not employed, retained or
otherwise had acted on his behalf any former County officer subject to the prohibition in Sec. 2
of Ordinance no. 10-1990 or any County officer or employee in violation of sec. 3 of Ordinance
10-1990, and that no employee or officer of the County had any interest, financially or otherwise,
in KPHA except for such interest, permissible by law and fully disclosed by affidavit attached
hereto. For breach or violation of this paragraph,the County may, in its discretion, terminate this
agreement without liability and may also, in its discretion, deduct from the contract or purchase
price, or otherwise recover, the full amount of any fee, commission, percentage, gift or
consideration paid to the former County officer or employee.
G. CONFLICT OF INTEREST: KPHA assures the County that to the best of its
knowledge information and belief, the signing of this agreement does not create conflict of
interest.
Page 5
H. OWNERSHIP OF INFORMATION: All Utilization Review and Case
Management documents which are prepared in the performance of this agreement are to be, and
shall remain, the property of the County and shall be transferred to the County or to a
replacement Utilization Review/Case Management service provider upon request and no later
than thirty (30) days after termination of this agreement. Any patient identifying information
shall not be disclosed without written consent of the patient.
I. INSURANCE REQUIREMENTS: KPHA is required to maintain the_types of •
insurance identified in Attachment B.
J. SEVERABILITY: If any provision of this Agreement is held to be illegal,
invalid, or unenforceable, under present or future laws effective during the term hereof, such
provision shall be fully severable. In such event, this Agreement shall be construed and enforced
as if the illegal invalid or unenforceable provision had never been a part hereof, and the
remaining provisions shall remain in full force and effect unaffected by such severance-provided
that if the illegal, invalid or unenforceable provision is material to the overall purpose..and
operation of this Agreement, then this Agreement shall terminate upon the severance of such
provision.
K. COUNTERPARTS: This Agreement and any amendment hereto may be
executed in multiple originals, all counterparts together constituting one and the same
instrument.
L. ENTIRE AGREEMENT: This Agreement, along with its exhibits, contains all
the terms and conditions agreed upon by the parties hereto regarding the subject matter of this
Agreement and supersedes any prior Agreements, promises, negotiations, or representations
either oral or written, relating to the subject matter of this Agreement.
M. HOLD HARMLESS: KPHA shall indemnify and hold the County harmless
from and against any and all losses, penalties, damages,professional fees, including attorney fees
and all costs of litigation and/or judgment arising out of any willful misconduct or negligent act,
error or omission of KPHA incidental to the performance of this agreement or work performed
thereunder. This indemnity shall extend to amounts the County becomes legally obligated,to pay
and shall be limited by any sovereign immunity limit applicable to the underlying claim plus
costs of litigation.
In witness wherof, the Employer and KPHA have caused this Agreement to be executed by their
respective corporate officers, effective as of the first day of October 2002.
Page 6
•
Employer: Board of Co Commissioners
of Monroe . Florida
By: C( Ai '/e .�onny����
Its: .ayar/Cyr i.t" 1CZh 9-VS o-
Keys Physician-Hospital Allianc
By:
Its: Pres i d
aS' > I8firr1{{}
Ira `ket
Imo- A .DANNYL
•
•
DEPUTYCLERK
APPROVED AS TO F
AND L SUFF I CY
7TON
�y
AN
gPPROVD ASSUFFI TOCI FO
AL
BY NNE
ATE
Page 7
Attachment A
Reimbursement Schedule
KPHA Members 85% of billed charges with the cap of the 90th percentile of the Medicode
Fee Schedule.
In County Providers(IPN) 85% of billed charges with the cap of the 90a percentile of the Medicode
Fee Schedule.
Out-of-County Providers(IPN) 70% of billed charges with the cap of the 90a percentile of the Medicode
Fee Schedule.
Dimension Providers Dimension Network Fee Schedule
Fisherman's Hospital 75% of billed charges.
•
Lower Keys Medical Center 75% of billed charges.
A list of specific providers and discount percentages will be provided to Acordia National by KPHA for
implementation.
James Roberts,County Administ Date
q � 0
Stephen Krathen,D.O. Date
KPHA President
1996 Edition
RISK MANAGEMENT
• POLICY AND PROCEDURES
CONTRACT ADMINISTRATION
MANUAL
General Insurance Requirements
for
Other Contractors and Subcontractors
As a pre-requisite of the work governed,or the goods supplied under this contract(including the
pre-staging of personnel and material),the Contractor shall obtain, at his/her own expense,
insurance as specified in any attached schedules,which are made part of this contract. The
Contractor will ensure that the insurance obtained will extend protection to all Subcontractors •
engaged by the Contractor. As an alternative,the Contractor may require all Subcontractors to
obtain insurance consistent with the attached schedules. •
The Contractor will not be permitted to commence work governed by this contract(including
• pre-staging of personnel and material)until satisfactory evidence of the required insurance has
been furnished to the County as specified below. Delays in the commencement of work,
resulting from the failure of the Contractor to provide satisfactory evidence of the required
insurance, shall not extend deadlines specified in this contract and any penalties and failure to
perform assessments shall be imposed as if the work commenced on the specified date and time,
except for the Contractor's failure to provide satisfactory evidence.
The Contractor shall maintain the required insurance throughout the entire term of this contract
and any extensions specified in the attached schedules. Failure to comply with this provision
may result in the immediate suspension of all work until the required insurance has been
reinstated or replaced. Delays in the completion of work resulting from the failure of the
Contractor to maintain the required insurance shall not extend deadlines specified in this contract
and any penalties and failure to perform assessments shall be imposed as if the work had not •
been suspended, except for the Contractor's failure to maintain the required insurance.
The Contractor shall provide, to the County,as satisfactory evidence of the required insurance,
either:
• Certificate of Insurance
or
• A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a certified copy of any or all insurance
policies required by this contract.
All insurance policies must specify that they are not subject to cancellation, non-renewal,
material change, or reduction in coverage unless a minimum of thirty (30) days prior notification
is given to the County by the insurer.
The acceptance and/or approval of the Contractor's insurance shall not be construed as relieving
the Contractor from any liability or obligation assumed under this contract or imposed by law.
Administration Instruction
#4709.3
14 •
1996 Edition
The Monroe County Board of County Commissioners, its employees and officials will be
included as''Additional Insured" on all policies, except for Workers' Compensation.
Any deviations.from.these General Insurance Requirements must be requested in writing on the
County prepared form entitled "Request for Waiver of Insurance Requirements" and
approved by Monroe County Risk Management.
Administration Instruction
#4709.3
15
1996 Edition
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY,FLORIDA
AND
Keys Physician-Hospital AIliance
Prior to the commencement of work governed by this contract,-the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract
and include, as a minimum:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Injury Liability
• Expanded Definition of Property Damage
The minimum Iimits acceptable shall be:
$500,000 Combined Single Limit(CSL)
If split limits,are provided, the minimum limits acceptable shall be:
$250,000 per Person •
$500,000 per Occurrence
$ 50,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy,its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition,the period for which claims may be reported should extend for a minimum of twelve
(12)months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
GL2
Administration Instruction
#4709.3 55
j
1996 Edition
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT,
BETWEEN
MONROE COUNTY,FLORIDA
AND
Keys Physician-Hospital.Alliance
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers'Compensation Insurance with limits sufficient to respond to Florida Statute 440.
In addition, the Contractor shall obtain Employers'Liability Insurance with limits of not less
than:
$100,000 Bodily Injury by Accident
• $500,000 Bodily Injury by Disease,policy limits
$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
If the Contractor has been approved by the Florida's Department of Labor,as an authorized self-
insurer, the County shall recognize and honor the Contractor's status. The Contractor may be
required to submit a Letter of Authorization issued by the Department of Labor and a Certificate
of Insurance,providing details on the Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund,a Certificate of Insurance will be required.
In addition,the Contractor may be required to submit updated financial statements from the fund
upon request from the County.
WC1
Administration Instruction
#4709.3
88
1996 Edition
PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Keys Physician-Hospital Alliance
Recognizing that the work governed by this contract involves the furnishing of advice or services -
of a professional nature,the Contractor shall purchase and maintain, throughout the life of the
contract,Professional Liability Insurance which will respond to damages resulting from any
claim arising out of the performance of professional services or any error or omission of the
Contractor arising out of work governed by this contract.
. The minimum limits of liability shall be:
$500,000 per Occurrence/$1,000,000 Aggregate
PRO2
Administration Instruction
#4709.3
78
1996 Edition
VEHICLE LIABILITY
• INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY,FLORIDA
AND
Keys Physician-Hospital Alliance
Recognizing that the work governed by this contract requires the use of vehicles,the Contractor,
prior to the commencement of work, shall obtain Vehicle Liability Insurance. Coverage shall be .
maintained throughout the life of the contract and include, as a minimum,liability coverage for:
• Owned,Non-Owned, and Hired Vehicles
The minimum limits acceptable shall be:
. $300,000 Combined Single Limit(CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
•
VL2
•
Administration Instruction
#4709.3
82
1996 Edition
EMPLOYEE DISHONESTY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY,FLORIDA
AND
Keys Physician-Hospital Alliance
The Contractor shall purchase and maintain, throughout the term of the contract,Employee
Dishonesty Insurance which will pay for losses to County property or money caused by the
fraudulent or dishonest acts of the Contractor's employees or its agents, whether acting alone or
in collusion of others.
The minimum limits shall be:
$10,000 per Occurrence
EDI
•
Administration Instruction
#4709.3
45
PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who has been placed on the convicted vendor list
following a conviction for public entity crime may not submit a bid on a
contract to provide any goods or services to a public entity, may not submit
a bid on a contract with a public entity for the construction or repair of a . •
public building or public work, may not submit bids on leases of real
property to public entity, may not be awarded or perform work as a
contractor, supplier, subcontractor, or consultant under a contract with any
public entity, and may not transact business with any-public entity in excess
of the threshold amount provided in Section 287.017,.for CATEGORY
TWO for a period of 36 months from the date of being.placed on the
convicted vendor list."
Exhibit D
KPHA Letter Defining Calculation
of Prompt Pay Discount
02/13/2003 14:16 FAX 304 353 8759 ACORDIA NATIONAL i�j002
j� Feb 12 03 04:31p kpha
30529608i?7 P-2
NNA 1116/0"
Keys Physician -Hospital Alliance
February 07,2003
Ms.Beverly Burdette
Vice President
Acordia National
602 Virginia Street,East
P.O.Box 3043
Charleston, WV 25331-3043
Dear Ms.Burdette:
•
The Keys Physician-Hospital Alliance performs the Utilization Review, Case Management and Quality
Assurance services for Monroe County. We also coordinate a network of providers- To that end,.our
contract stipulates the reimbursement for services to be as follows:
KPHA Member 85%of billed charges with the cap of the 90th percentile of the
Medicode Fee Schedule
In County Providers(IPN) • 85% of billed charges with the cap of the 90t percentile of the
Medicode Fee Schedule
Out of County Providers(TPN) 70% of billed charges with the cap of the 90th percentile of the
Medicode Fee Schedule
Dimension Providers Dimension Network Fee Schedule
Fisherman's Hospital 75%of billed charges
Lower Keys Medical Center • 75%of billed charges
Our understanding is that if the physician's billed charge exceeds the 90*percentile of the Medicode Fee
Schedule that the 90"'percentile will be utilized as the base reimbursement and the discount shall then be
applied, Please see examples listed below utilizing the KPHA and In County Network Provider
Reimbursement Schedule:
Example 1: . Base Charge does not exceed the 90th Percentile of Medicode
S 100.00 Billed Charge
15.00 15%Discount •
$ 85.00 Covered Amount(Minus.pt.responsibility,co pays and deductibles)
PA).Box 911171 Key Wan.Florida 131N1-9107
(3115)2944:599 111t'(305)294_9376
FEB-12-2003 16:30 .slab 9b0B27 92% P.02
02/13/2003 14:16 FAX 304 353 8759 ACORDIA NATIONAL Z003
Feb 12 03 04:31p kpha 3052960927 p,3
Example 2: Base Charee exceeds 90`h percentile of the Medicode Fee Schedule
$100.00 Billed Charge
90.00 90a Percentile of the Medicode Fee Schedule
13.50 15% Discount
$ 76.50 Covered Amount(Minus pt.responsibility,co pays and deductibles)
Please do not hesitate to contact me should you require additional information.
Sincerely,,,---)
David a\ ,M.D.
Presiden
CC: James Roberts,County Administrator
Danny Kohlage,Clerk of Courts
DB/mfw
•
FEB-12-2003 16:30 3052960827 92% P.03
Exhibit E
Acordia Explanation of Benefit
EXPLANATION OF BENEFITS ***THIS IS NOT A BILL***
'' ordia. MONROE CNTY f3 . rOMMISSION '•COMPANYA ,830-01-M
P cth CA3E..�.N CLAM `'::::';:'`::: A:� 169319
Acordia National ;MM1::';ti:; , ;;:«•`::> :#:'•:
' AGE: 1 OF 1 : "••lE•.>::.. . :^:::::• :.. . .
pA'����{�•;::lai��.•;::. . >�k1�CK#l�A'FE>zz`" 11/25/2002
CLIENT COPY 0. * E «: GE009 iie.i.e4Kiillgigilerite 159970
•
:. ou)��rtante.:.s��..�rvi�,e.:::::::::::::::::::... ....................................�r�u€................. :.;:;.;:::;:.-.d:.::;:;:::.:.:;:::;.:;::>:;:>:>;:::.;>::��:........_.. .._........ ................... ......�........_...,..... . ..........
•
....... ._ ........ :::>:;::::::: <:=:>:::��nvmr. .::.�:: .:...........::::::::.:::.� .. ..:.:.::.::.:..II#her...:.................................
a...�#...&ervice............................... :.:...,............a. .:::. ..:.:. ...............................
--S: 11/01/02-11/01/02
6415-DIAGNOSTIC SRVC 15.00 15.00AH
0061-DIAGNOSTIC SRVC 50.00 7.50 42.50 80 34.00 34.00
85027-DIAGNOSTIC SRVC 20.00 3.00 17.00 80 13.60 13.60
93000-DIAGNOSTIC SRVC 70.00 10.50 59.50 80 47.60 47.60
_ 3224-DIAGNOSTIC SRVC 384.00 57.60 326.40 80 261.12 261.12
9204-OFFICE VISITS 286:00 42.90 243.10 80 194.48 194.48
•
r
:.:::.; :•<'•:•; . ,::.;:.:.>:. .::. :.� ..::.:: . .>;ethed.: aid..lS.Y,:::::::::::?a. ::.;:.:<.::.a„R+ent Calculation: ::>:::� ar: >:<::�:<zz:<;::::p .... .:>isi;'si:i::•�:�.. ;::::><>>.:.:>:::;::::..:,..»�:•.z:<;:>::s: . :::::.:. ::::°/a:.:;•.. ::.::::::. ....::>::::::..:. hT,...9es.............EtElkcotdkt........�d.�y...:.,.riot::.CQusred�;::.;:.::;:.;:...;lvYera�::.;:;.:t7esiuctlb�e.;,.;>;•:::::;:F1a�:<:8e��:f�t�:::::�ither.::.<<It��ur��r�e:::::;:;;:�>:>.#?aed:>:;::�:>.:
GRAND TOTALS 825.00 121.50 15.00 688.50 550.80 550.80
•
PAY PROVIDER AMOUNT DUE ---> PATIENT RESPONSIBILITY: 152. 70
mMagNENNMENggiMAuxgRMOOlgppplAid••:
A 1i REM14'I3�tING....
iL.JIDUAL DEDUCTIBLE 300.00 0.00 FAMILY DEDUCTIBLE 300.00 300.00
4TIENT NOT RESPONSIBLE FOR DISCOUNT - NETWORK: KEYS PHYSICIAN - HOSPITAL ALLIANCE 2002112500000025
$ECOAC1f> ? '> : > ?>::»»:><::::: ><
. °LOYER: MONROE CNTY BRD OF COMMISSION PROVIDER PAID
550.80
PROV ID
•
NON NEGOTIABLE
Exhibit F
KPHA Network Payments Memo
From Richard H. Legg Sr. VP/COO
02/05/2003 13:25 FAX 30529536P, INTERNAL AUDIT
�, el001/002
FEB-05-2003 12 t 28 'x
P.01
Acordia National
(02 Virginia titrwl_Fast
is r'.0 110v 043(25'331.3043)
AcordiaNational /oice:304.353,87n
f me;d0,353,1i7a8
FACSIMILE TRANSMITTAL SHEET
February 5, 2003
Y To: Sandy Mathena Procne
Richard H. Lecg, $r,VP/Cpp
Location: Monroe County R ,
e• KPHA Network Payments
Fax: 305-295.3880 Pages:_- 9 1 (excluding ccver page)
Comments:
Acordia National procesl;ea Physician Claims for the KPHA Network In
accordance with the altiich.d contract fee schedule, with some
exceptions:
1. We take the total cltairge and multiply it b;f 15%, and then compare it
with the 1997 Medic;ode Fee Schedule that is loaded in our system and
allow the lesser am aunt of the two.
Exceptions:
1. If there is no fee schtdule amount of the CPT Code, we take the charge
and multiply it times 15% discount.
2. If the total charge 1.5 less than the fee schedule amount, we take the
total charge and milli:iply it times the 15% discount.
3. In addition, we have had seversi provider!: that have questioned the old
fee schedule and halve informed us that their contract says it is a 15%
discount, so we have used this 15% figure rather than the fee schedule,
once again because it is over 6 years old.
Due tb the complexities :Issociated with this old fee schedule, we have
discovered that we have used the 15% discount In situations where we
should have used the f?e schedule. We are reviewing this t(3 see if
adjustments to some claims need to be done.
confidentiality Not ice; The infotm.3tion contained in this facsimile message, and in any accompanying documents,
constitutes confidential information which k :longs to Acerdia. This information is intended only for the use of the individual or
entity named above. If you are not the intended recipient of this informal on, you are hereby not fled that any disclosure,
commugnicationunon or the error please gmmed of i o y notify us by telephone ac.:ion in reliance on this �r:turn is strictly you have eadd address
above via the U.S.Postal Service. message to us at the address
If you do not receive the entire fax, p'lase contact sender limed ately,
02/65/2003 13:28 FAX 30529538 INTERNAL AUDIT
FEE-05-'?003 12:2B f�002/002
•
•
•
•
Attachment A
Reimbursement$ehecfule
tf PHA Members _ �
85 y, of billed;Lung with the cap Cl Hsi 9U" pereeutilt of the Medlcode
Pee Schedule.
1n County Providers(IPN) 8514. of billed ehergee with the sap of the 90° pereentlle of the Medicode
Fee Schedule.
Out r Couoty Providers(I?N) 70% of billed cbsrgeswith the cap of the 90° percentile of the Medic-ode
Fee Schedule.
Dimeesiao Providers Dimension Network FeeSchedu'e
Fisherman's Hospital 75% of billed charges.
Lower Keys Medical Center 75% of billed charges.
A list of specific providers and disr.rant percentages wig be provided to Aeordie Netiocal by KlailA fur
implementation.
James Roberts,County A straO7 :: L
m
Stephen Kra then,D. .
KPRA President Date
•
TOTAL P.02
Exhibit G
Acordia's Preliminary 2003 Schedule Of
Overpayments
MCCLM_INE NSX MCBDOS MCPDDT 7,PPOD CMED97:;MEDCUR AYS MEDDAYS MCCLMD CPER\CTDISC:CORDISC;DIFFDISC MCACTALL MCCORALL NCDUCT NPER1 ACTPAID1 ER2 CTPAID2 CTPAIDT:CORPAID)IFFPAID
174884 1 20021231 1312003 KPHA 193.00 271.29 1 271.29 302.00 15 45.30 40.69 4.61 256.70 271.29 0.00 80 256.70 0 0.00 205.36 184.48 20.88
172821 1 20021213 1102003 KPHA 193.00 271.29 1 271.29 302.00 15 45.30 40.69 4.61 256.70 271.29 0.00 80 256.70 0 0.00 205.36 184.48 20.88
176376 2 20030209 2262003 KPHA 361.75 288.53 1 288.53 315.00 15 47.25 43.28 3.97 267.75 288.53 0.00 100 267.75 0 0.00 267.75 245.25 22.50
174499 5 20030107 1292003 KPHA 101.85 106.85 1 106.85 140.00 15 21.00 16.03 4.97 119.00 106.85 0.00 80 119.00 0 0.00 95.20 72.66 22.54
172606 4 20021211 1102003 KPHA 85.10 106.65 1 106.65 140.00 15 21.00 16.00 5.00 119.00 106.65 0.00 80 119.00 0 0.00 95.20 72.52 22.68
174499 6 20030107 1292003 KPHA 86.86 106.34 1 106.34 140.00 15 21.00 15.95 5.05 119.00 106.34 0.00 80 119.00 0 0.00 95.20 72.31 22.89
173661 1 20021231 1222003 KPHA 211.30 189.89 1 189.89 217.00 15 32.55 28.48 4.07 184.45 189.89 0.00 100 184.45 0 0.00 184.45 161.41 23.04
171987 1 20021209 1082003 KPHA 206.74 161.60 1 161.60 196.00 15 29.40 24.24 5.16 166.60 161.60 0.00 80 166.60 0 0.00 133.28 109.89 23.39
174293 1 20021222 1242003 KPHA 193.00 271.29 1 271.29 302.00 15 45.30 40.69 4.61 256.70 271.29 0.00 100 256.70 0 0.00 256.70 230.60 26.10
174499 3 20030107 1292003 KPHA 114.86 100.35 1 100.35 140.00 15 21.00 15.05 5.95 119.00 100.35 0.00 80 119.00 0 0.00 95.20 68.24 26.96
175024 1 20021223 2132003 KPHA 334.76 410.03 1 410.03 450.00 15 67.50 61.50 6.00 382.50 410.03 0.00 80 382.50 0 0.00 306.00 278.82 27.18
175604 2 20030124 2142003 KPHA 3064.29 1620.12 1 1620.12 1663.00 15 249.45 243.02 6.43 1413.55 1620.12 0.00 80 1413.55 0 0.00 1130.84 1101.68 29.16
175599 2 20030123 2142003 KPHA 3064.29 1620.12 1 1620.12 1663.00 15 249.45 243.02 6.43 1413.55 1620.12 0.00 80 1413.55 0 0.00 1130.84 1101.68 29.16
173798 3 20030106 1222003 KPHA 102.76 101.53 1 101.53 145.00 15 21.75 15.23 6.52 123.25 101.53 0.00 80 123.25 0 0.00 98.60 69.04 29.56
173686 4 20021230 1222003 KPHA 114.86 100.35 1 100.35 145.00 15 21.75 15.05 6.70 123.25 100.35 0.00 80 123.25 0 0.00 98.60 68.24 30.36
174477 5 20021209 1292003 KPHA 46.99 50.64 1 50.64 90.00 15 13.50 7.60 5.90 76.50 50.64 0.00 100 76.50 0 0.00 76.50 43.04 33.46
176066 2 20030129 2192003 KPHA 345.92 245.99 1 245.99 296.00 15 44.40 36.90 7.50 251.60 245.99 0.00 80 251.60 0 0.00 201.28 167.27 34.01
174924 2 20030114 2052003 KPHA 303.81 213.72 1 213.72 264.00 15 39.60 32.06 7.54 224.40 213.72 0.00 80 224.40 0 0.00 179.52 145.33 34.19
174474 3 20021223 1292003 KPHA 6.31 11.95 57 681.15 684.00 15 102.60 102.17 0.43 581.40 681.15 0.00 80 415.30 100 166.10 498.34 463.18 35.16
173686 5 20021230 1222003 KPHA 25.69 32.43 1 32.43 85.00 15 12.75 4.86 7.89 72.25 32.43 0.00 80 72.25 0 0.00 57.80 22.06 35.74
174499 8 20030107 1292003 KPHA 47.41 54.89 1 54.89 110.00 15 16.50 8.23 8.27 93.50 54.89 0.00 80 93.50 0 0.00 74.80 37.33 37.47
172038 1 20021216 1082003 KPHA 93.10 103.90 1 103.90 164.00 15 24.60 15.59 9.01 139.40 103.90 0.00 80 139.40 0 0.00 111.52 70.65 40.87
176376 3 20030209 2262003 KPHA 345.92 245.99 1 245.99 296.00 15 44.40 36.90 7.50 251.60 245.99 0.00 100 251.60 0 0.00 251.60 209.09 42.51
173686 10 20021230 1222003 KPHA 37.70 34.82 1 34.82 100.00 15 15.00 5.22 9.78 85.00 34.82 0.00 80 85.00 0 0.00 68.00 23.68 44.32
171341 2 20021111 1292003 KPHA 82.21 43.52 1 43.52 105.00 15 15.75 6.53 9.22 89.25 43.52 0.00 100 89.25 0 0.00 89.25 36.99 52.26
173752 2 20030108 1222003 KPHA 981.91 1218.35 1 1218.35 1300.00 15 195.00 182.75 12.25 1105.00 1218.35 0.00 80 1105.00 0 0.00 884.00 828.48 55.52
173161 3 20021213 1152003 KPHA 135.73 108.47 1 108.47 175.00 15 26.25 16.27 9.98 148.75 108.47 0.00 100 148.75 0 0.00 148.75 92.20 56.55
175395 1 20030106 2132003 KPHA 264.11 247.21 1 247.21 337.00 15 50.55 37.08 13.47 286.45 247.21 0.00 80 286.45 0 0.00 229.16 168.10 61.06
174641 1 20021220 1312003 KPHA 283.31 354.58 1 354.58 400.00 15 60.00 53.19 6.81 340.00 354.58 0.00 80 173.25 100 166.75 305.35 241.11 64.24
172040 1 20021216 1082003 KPHA 267.46 207.69 1 207.69 286.00 15 42.90 31.15 11.75 243.10 207.69 0.00 100 243.10 0 0.00 243.10 176.54 66.56
173686 11 20021230 1222003 KPHA 69.20 78.19 1 78.19 180.00 15 27.00 11.73 15.27 153.00 78.19 0.00 80 153.00 0 0.00 122.40 53.17 69.23
172310 2 20021212 1172003 KPHA 302.94 193.83 1 193.83 300.00 15 45.00 29.07 15.93 255.00 193.83 2.50 80 252.50 0 0.00 202.00 129.81 72.19
176659 2 20030206 2262003 KPHA 3064.29 1620.12 1 1620.12 1730.00 15 259.50 243.02 16.48 1470.50 1620.12 0.00 80 1470.50 0 0.00 1176.40 1101.68 74.72
165370 4 A 20020923 1152003 KPHA 37.70 33.87 1 33.87 160.00 15 24.00 5.08 18.92 136.00 33.87 0.00 100 136.00 0 0.00 136.00 28.79[1-17.97
172204 2 20021210 1082003 KPHA 3064.29 1620.12 1 1620.12 1783.00 15 267.45 243.02 24.43 1515.55 1620.12 0.00 80 1515.55 0 0.00 1212.44 1101.68 110.76
174027 5 20030103 1222003 KPHA 3064.29 1620.12 1 1620.12 1783.00 15 267.45 243.02 24.43 1515.55 1620.12 0.00 80 1515.55 0 0.00 1212.44 1101.68 110.76
173686 9 20021230 1222003 KPHA 128.15 179.03 1 179.03 390.00 15 58.50 26.85 31.65 331.50 179.03 0.00 80 331.50 0 0.00 265.20 121.74 143.46
174352 1 20020715 1242003 KPHA 183.56 207.06 1 207.06 424.64 5 21.23 10.35 10.88 403.41 207.06 0.00 100 403.41 0 0.00 403.41 196.71 206.70
173752 3 20030108 1222003 KPHA 677.18 840.24 1 840.24 1150.00 15 172.50 126.04 46.46 977.50 840.24 0.00 80 977.50 0 0.00 782.00 571.36 210.64
173431 2 20021217 1172003 KPHA 235.35 281.93 1 281.93 1479.00 15 221.85 42.29 179.56 1257.15 281.93 0.00 80 1257.15 0 0.00 1005.72 191.71 814.01
174957 1 20030122 2052003 KPHA 5707.89 4095.60 1 4095.60 8136.00 15 1220.40 614.34 606.06 6915.60 4095.60 300.00 80 6615.60 0 0.00 5292.48 2545.01 !1114.97
5073.45 '
-163.14
4910.31
Qof% - _ -
MCCLM_INENSX MCBDOS MCPDDT:::PPODCMED97:MEDCURAYSMEDDAYS MCCLMDCPER\CTDISC:CORDISC:DIFFDISCMCACTALLMCCORALLNCDUCTNPER1ACTPAID1ER2CTPAID2�TPAIDT;CORPAID)IFFPAID
173324 1 20021226 1152003 KPHA 246.13 346.79 1 346.79 359.00 15 53.85 52.02 1.83 305.15 346.79 0.00 80 305.15 0 0.00 244.12 235.82 8.30
173686 8 20021230 1222003 KPHA 26.22 32.26 1 . 32.26 45.00 15 6.75 4.84 1.91 38.25 32.26 0.00 80 38.25 0 0.00 30.60 21.94 8.66
172811 4 20021218 1102003 KPHA 484.07 255.93 1 255.93 270.00 15 40.50 38.39 2.11 229.50 255.93 0.00 80 229.50 0 0.00 183.60 174.03 9.57
175194 3 20030122 2132003 KPHA 484.07 255.93 1 255.93 270.00 15 40.50 38.39 2.11 229.50 255.93 0.00 80 229.50 0 0.00 183.60 174.03 9.57
175604 4 20030124 2142003 KPHA 484.07 255.93 1 255.93 270.00 15 40.50 38.39 2.11 229.50 255.93 0.00 80 229.50 0 0.00 183.60 174.03 9.57
172204 4 20021210 1082003 KPHA 484.07 255.93 1 255.93 270.00 15 40.50 38.39 2.11 229.50 255.93 0.00 80 229.50 0 0.00 183.60 174.03 9.57
176659 4 20030206 2262003 KPHA 484.07 255.93 1 255.93 270.00 15 40.50 38.39 2.11 229.50 255.93 0.00 80 229.50 0 0.00 183.60 174.03 9.57
174027 7 20030103 1222003 KPHA 484.07 255.93 1 255.93 270.00 15 40.50 38.39 2.11 229.50 255.93 0.00 80 229.50 0 0.00 183.60 174.03 9.57
175599 4 20030123 2142003 KPHA 484.07 255.93 1 255.93 270.00 15 40.50 38.39 2.11 229.50 255.93 0.00 80 229.50 0 0.00 183.60 174.03 9.57
173696 4 20021226 1222003 KPHA 60.63 63.41 1 63.41 75.00 15 11.25 9.51 1.74 63.75 63.41 0.00 100 63.75 0 0.00 63.75 53.90 9.85
174499 1 20030107 1292003 KPHA 89.71 125.32 1 125.32 140.00 15 21.00 18.80 2.20 119.00 125.32 21.75 80 97.25 0 0.00 77.80 67.82 9.98
173686 2 20021230 1222003 KPHA 89.71 125.32 1 125.32 140.00 15 21.00 18.80 2.20 119.00 125.32 0.00 80 119.00 0 0.00 95.20 85.22 9.98
173025 2 20021230 1152003 KPHA 105.57 105.03 1 105.03 120.00 15 18.00 15.75 2.25 102.00 105.03 0.00 80 102.00 0 0.00 81.60 71.42 10.18
174928 7 20030114 2052003 KPHA 76.55 62.50 1 62.50 75.00 15 11.25 9.38 1.87 63.75 62.50 0.00 100 63.75 0 0.00 63.75 53.12 10.63
174759 1 20021220 1312003 KPHA 128.54 138.74 1 138.74 150.00 5 7.50 6.94 0.56 142.50 138.74 0.00 100 142.50 0 0.00 142.50 131.80 10.70
172488 6 20021205 1102003 KPHA 128.15 179.03 1 179.03 195.00 15 29.25 26.85 2.40 165.75 179.03 0.00 80 165.75 0 0.00 132.60 121.74 10.86
172495 6 20021210 1102003 KPHA 128.15 179.03 1 179.03 195.00 15 29.25 26.85 2.40 165.75 179.03 0.00 80 165.75 0 0.00 132.60 121.74 10.86
172504 4 20021212 1102003 KPHA 37.71 43.66 1 43.66 60.00 15 9.00 6.55 2.45 51.00 43.66 31.40 80 19.60 0 0.00 15.68 4.57 11.11
172480 4 20021209 1102003 KPHA 37.71 43.66 1 43.66 60.00 15 9.00 6.55 2.45 51.00 43.66 0.00 80 51.00 0 0.00 40.80 29.69 11.11
172524 5 20021210 1102003 KPHA 37.71 43.66 1 43.66 60.00 15 9.00 6.55 2.45 51.00 43.66 0.00 80 51.00 0 0.00 40.80 29.69 11.11
174397 3 20021219 1292003 KPHA 37.71 43.66 1 43.66 60.00 15 9.00 6.55 2.45 51.00 43.66 0.00 80 51.00 0 0.00 40.80 29.69 11.11
173253 1 20021222 1152003 KPHA 289.01 333.45 1 333.45 350.00 15 52.50 50.02 2.48 297.50 333.45 0.00 80 297.50 0 0.00 238.00 226.74 11.26
173251 1 20021220 1152003 KPHA 289.01 333.45 1 333.45 350.00 15 52.50 50.02 2.48 297.50 333.45 0.00 80 297.50 0 0.00 238.00 226.74 11.26
176369 1 20030204 2262003 KPHA 151.91 125.34 1 125.34 142.00 15 21.30 18.80 2.50 120.70 125.34 67.50 80 53.20 0 0.00 42.56 31.23 11.33
173162 3 20021213 1152003 KPHA 78.14 66.46 1 66.46 80.00 15 12.00 9.97 2.03 68.00 66.46 0.00 100 68.00 0 0.00 68.00 56.49 11.51
173204 2 20020830 1152003 KPHA 246.13 340.42 1 340.42 359.00 15 53.85 51.06 2.79 305.15 340.42 0.00 80 305.15 0 0.00 244.12 231.49 12.63
172449 1 20021216 1102003 KPHA 111.00 148.95 1 148.95 168.00 15 25.20 22.34 2.86 142.80 148.95 0.00 80 142.80 0 0.00 114.24 101.29 12.95
172588 1 20021206 1102003 KPHA 111.00 148.95 1 148.95 168.00 15 25.20 22.34 2.86 142.80 148.95 0.00 80 142.80 0 0.00 114.24 101.29 12.95
172182 1 20021210 1082003 KPHA 111.00 148.95 1 148.95 168.00 15 25.20 22.34 2.86 142.80 148.95 0.00 80 142.80 0 0.00 114.24 101.29 12.95
172446 1 20021216 1102003 KPHA 11.1.00 148.95 1 148.95 168.00 15 25.20 22.34 2.86 142.80 148.95 0.00 80 142.80 0 0.00 114.24 101.29 12.95
172183 1 20021211 1082003 KPHA 111.00 148.95 1 148.95 168.00 15 25.20 22.34 2.86 142.80 148.95 0.00 80 142.80 0 0.00 114.24 101.29 12.95
175599 9 , 20030128 2142003 KPHA 111.00 148.95 1 148.95 168.00 15 25.20 22.34 2.86 142.80 148.95 0.00 80 142.80 0 0.00 114.24 101.29 12.95
172039 2 20021217 1082003 KPHA 188.78 109.66 1 109.66 130.00 15 19.50 16.45 3.05 110.50 109.66 0.00 80 110.50 0 0.00 88.40 74.57 13.83
174309 7 20021206 1242003 KPHA 37.71 43.66 1 43.66 60.00 15 9.00 6.55 2.45 51.00 43.66 0.00 100 51.00 0 0.00 51.00 37.11 13.89
172670 1 20021110 1102003 KPHA 289.01 333.45 1 333.45 350.00 15 52.50 50.02 2.48 297.50 333.45 0.00 100 297.50 0 0.00 297.50 283.43 14.07
174925 3 20030114 2052003 KPHA 151.91 125.34 1 125.34 142.00 15 21.30 18.80 2.50 120.70 125.34 0.00 100 120.70 0 0.00 120.70 106.54 14.16
172656 5 20021017 1102003 KPHA 289.01 328.73 1 328.73 350.00 15 52.50 49.31 3.19 297.50 328.73 0.00 80 297.50 0 0.00 238.00 223.54 14.46
172657 2 20021016 1102003 KPHA 289.01 328.73 1 328.73 350.00 15 52.50 49.31 3.19 297.50 328.73 0.00 80 297.50 0 0.00 238.00 223.54 14.46
174499 4 20030107 1292003 KPHA 25.69 32.43 1 32.43 55.00 15 8.25 4.86 3.39 46.75 32.43 0.00 80 46.75 0 0.00 37.40 22.06 15.34
172525 2 20021211 1102003 KPHA 19.77 22.34 1 22.34 45.00 15 6.75 3.35 3.40 38.25 22.34 0.00 80 38.25 0 0.00 30.60 15.19 15.41
172450 1 20021213 1102003 KPHA 111.00 148.95 1 148.95 168.00 15 25.20 22.34 2.86 142.80 148.95 0.00 100 142.80 0 0.00 142.80 126.61 16.19
173695 3 20030103 1222003 KPHA 297.66 307.17 1 307.17 331.00 15 49.65 46.08 3.57 281.35 307.17 216.70 80 64.65 0 0.00 51.72 35.51 16.21
169666 3 20021028 1222003 KPHA 399.48 249.84 1 249.84 274.00 15 41.10 37.48 3.62 232.90 249.84 0.00 80 232.90 0 0.00 186.32 169.89 16.43
174320 2 20021204 1242003 KPHA 32.51 35.10 1 35.10 60.00 15 9.00 5.27 3.73 51.00 35.10 0.00 80 51.00 0 0.00 40.80 23.86 16.94
173276 1 20021217 1152003 KPHA 128.54 138.74 2 277.48 300.00 5 15.00 13.87 1.13 285.00 277.48 0.00 80 285.00 0 0.00 228.00 210.89 17.11
173152 1 20021212 1152003 KPHA 31.33 33.76 1 33.76 60.00 15 9.00 5.06 3.94 51.00 33.76 0.00 80 51.00 0 0.00 40.80 22.96 ' 17.84
174186 2 20021205 1242003 KPHA 107.16 85.63 1 85.63 112.00 15 16.80 12.84 3.96 95.20 85.63 0.00 80 95.20 0 0.00 76.16 58.23 17.93
172787 4 20021111 1102003 KPHA 44.99 53.90 1 53.90 75.00 15 11.25 8.09 3.16 63.75 53.90 0.00 100 63.75 0 0.00 63.75 45.81 17.94
172959 4 20021125 1152003 KPHA 44.99 53.90 1 53.90 75.00 15 11.25 8.09 3.16 63.75 53.90 0.00 100 63.75 0 0.00 63.75 45.81 17.94
173248 4 20021202 1152003 KPHA 44.99 53.90 1 53.90 75.00 15 11.25 8.09 3.16 63.75 53.90 0.00 100 63.75 0 0.00 63.75 45.81 17.94
176066 1 20030129 2192003 KPHA 361.75 288.53 1 288.53 315.00 15 47.25 43.28 3.97 267.75 288.53 243.90 80 23.85 0 0.00 19.08 1.08 18.00
172651 1 20021218 1102003 KPHA 132.73 128.45 1 128.45 150.00 15 22.50 19.27 3.23 127.50 128.45 0.00 100 127.50 0 0.00 127.50 109.18 18.32
175909 1 20030205 2142003 KPHA 310.63 271.74 1 271.74 300.00 15 45.00 40.76 4.24 255.00 271.74 0.00 80 255.00 0 0.00 204.00 184.78 19.22
175507 2 20021210 2142003 KPHA 164.84 101.56 1 101.56 130.00 15 19.50 15.23 4.27 110.50 101.56 0.00 80 110.50 0 0.00 88.40 69.06 19.34
172336 2 20021213 1082003 KPHA 164.84 101.56 1 101.56 130.00 15 19.50 15.23 4.27 110.50 101.56 0.00 80 110.50 0 0.00 88.40 69.06 19.34
171934 1 20021021 1082003 KPHA 76.59 102.19 1 102.19 125.00 15 18.75 15.33 3.42 106.25 102.19 0.00 100 106.25 0 0.00 106.25 86.86 19.39
174924 1 20030114 2052003 KPHA 311.85 250.65 1 250.65 280.00 15 42.00 37.60 4.40 238.00 250.65 0.00 80 238.00 0 0.00 190.40 170.44 19.96
173696 1 20021226 1222003 KPHA 31.63 35.74 1 35.74 60.00 15 9.00 5.36 3.64 51.00 35.74 0.00 100 51.00 0 0.00 51.00 30.38 20.62
174394 1 20021223 1292003 KPHA 193.00 271.29 1 271.29 302.00 15 45.30 40.69 4.61 256.70 271.29 0.00 80 256.70 0 0.00 205.36 184.48 20.88
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173478 1 20021222 1172603 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
173478 2 20021217 1172003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 .199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
175496 1 20030110 2142003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
173442 1 20021216 1172003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
173443 1 20021216 1172003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
173074 1 20021201 1152003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
173445 1 20021220 1172003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
174186 1 20021205 1242003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
173430 1 20021214 1172003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
173338 2 20021219 1152003 KPHA 206.14 164.42 4 657.68 320.00 15 48.00 48.00 0.00 272.00 320.00 0.00 100 272.00 0 0.00 272.00 272.00 0.00
' 173338 3 20021219 1152003 KPHA 206.14 164.42 6 986.52 480.00 15 72.00 72.00 0.00 408.00 480.00 0.00 100 408.00 0 0.00 408.00 408.00 0.00
176591 2 20030206 2262003 KPHA 206.14 164.42 4 657.68 400.00 15 60.00 60.00 0.00 340.00 400.00 0.00 80 340.00 0 0.00 272.00 272.00 0.00
176591 3 20030206 2262003 KPHA 206.14 164.42 6 986.52 600.00 15 90.00 90.00 0.00 510.00 600.00 0.00 80 510.00 0 0.00 408.00 408.00 0.00
176041 2 20030123 2192003 KPHA 206.14 164.42 3 493.26 300.00 15 45.00 45.00 0.00 255.00 300.00 0.00 80 255.00 0 0.00 204.00 204.00 0.00
176041 3 20030123 2192003 KPHA 206.14 164.42 4 657.68 400.00 15 60.00 60.00 0.00 340.00 400.00 0.00 80 340.00 0 0.00 272.00 272.00 0.00
174509 2 20030109 1292003 KPHA 206.14 164.42 4 657.68 400.00 15 60.00 60.00 0.00 340.00 400.00 130.00 80 210.00 0 0.00 168.00 168.00 0.00
174509 3 20030109 1292003 KPHA 206.14 164.42 6 986.52 600.00 15 90.00 90.00 0.00 510.00 600.00 0.00 80 510.00 0 0.00 408.00 408.00 0.00
174471 1 20021224 1292003 KPHA 216.65 271.15 1 271.15 255.00 15 38.25 38.25 0.00 216.75 255.00 0.00 80 216.75 0 0.00 173.40 173.40 0.00
175576 2 20021226 2142003 KPHA 227.36 262.31 6 1573.86 834.00 15 125.10 125.10 0.00 708.90 834.00 0.00 100 708.90 0 0.00 708.90 708.90 0.00
175577 1 20030101 2142003 KPHA 227.36 262.31 7 1836.17 973.00 15 145.95 145.95 0.00 827.05 973.00 0.00 100 827.05 0 0.00 827.05 827.05 0.00
175577 3 20030125 2142003 KPHA 227.36 262.31 5 1311.55 695.00 15 104.25 104.25 0.00 590.75 695.00 0.00 100 590.75 0 0.00 590.75 590.75 0.00
172656 3 20021012 1102003 KPHA 231.21 337.41 1 337.41 275.00 15 41.25 41.25 0.00 233.75 275.00 0.00 80 233.75 0 0.00 187.00 187.00 0.00
174474 2 20021212 1292003 KPHA 283.31 354.58 1 354.58 350.00 15 52.50 52.50 0.00 297.50 350.00 0.00 80 297.50 0 0.00 238.00 238.00 0.00
173344 1 20021230 1152003 KPHA 283.31 354.58 1 354.58 290.00 15 43.50 43.50 0.00 246.50 290.00 0.00 100 246.50 0 0.00 246.50 246.50 0.00
176650 1 20030117 2262003 KPHA 288.27 405.21 1 405.21 324.00 15 48.60 48.60 0.00 275.40 324.00 0.00 80 275.40 0 0.00 220.32 220.32 0.00
174184 1 20021227 1242003 KPHA 288.27 405.21 1 405.21 324.00 15 48.60 48.60 0.00 275.40 324.00 0.00 80 275.40 0 0.00 220.32 220.32 0.00
173072 1 20021206 1152003 KPHA 288.27 405.21 1 405.21 324.00 15 48.60 48.60 0.00 275.40 324.00 0.00 100 275.40 0 0.00 275.40 275.40 0.00
173348 1 20021212 1152003 KPHA 288.27 405.21 1 405.21 324.00 15 48.60 48.60 0.00 275.40 324.00 0.00 100 275.40 0 0.00 275.40 275.40 0.00
173349 1 20021208 1152003 KPHA 288.27 405.21 1 405.21 324.00 15 48.60 48.60 0.00 275.40 324.00 0.00 80 275.40 0 0.00 220.32 220.32 0.00
173431 1 20021217 1172003 KPHA 288.27 405.21 1 405.21 324.00 15 48.60 48.60 0.00 275.40 324.00 0.00 80 275.40 0 0.00 220.32 220.32 0.00
174315 2 20021215 1242003 KPHA 288.27 405.21 1 405.21 324.00 15 48.60 48.60 0.00 275.40 324.00 0.00 80 275.40 0 0.00 220.32 220.32 0.00
173073 1 20021201 1172003 KPHA 288.27 405.21 1 405.21 324.00 15 48.60 48.60 0.00 275.40 324.00 0.00 80 275.40 0 0.00 220.32 220.32 0.00
174185 1 20021221 1242003 KPHA 288.27 405.21 1 405.21 324.00 15 48.60 48.60 0.00 275.40 324.00 0.00 80 275.40 0 0.00 220.32 220.32 0.00
173446 1 20021214 1172003 KPHA 288.27 405.21 1 405.21 324.00 15 48.60 48.60 0.00 275.40 324.00 0.00 80 275.40 0 0.00 220.32 220.32 0.00
174187 1 20021225 1242003 KPHA 288.27 405.21 1 405.21 324.00 15 48.60 48.60 0.00 275.40 324.00 0.00 80 275.40 0 0.00 220.32 220.32 0.00
172595 1 20021218 1102003 KPHA 416.72 531.40 1 531.40 450.00 15 67.50 67.50 0.00 382.50 450.00 0.00 80 382.50 0 0.00 306.00 306.00 0.00
174181 1 20021230 1242003 KPHA 429.97 604.38 1 604.38 443.00 15 66.45 66.45 0.00 376.55 443.00 0.00 100 376.55 0 0.00 376.55 376.55 0.00
172174 1 20021211 1082003 KPHA 20.11 25.38 1 25.38 26.00 15 3.90 3.81 0.09 22.10 25.38 0.00 80 22.10 0 0.00 17.68 17.26 0.42
172592 2 20021213 1102003 KPHA 20.11 25.38 1 25.38 26.00 15 3.90 3.81 0.09 22.10 25.38 0.00 100 22.10 0 0.00 22.10 21.57 0.53
171918 4 20021218 1082003 KPHA 97.20 119.00 1 119.00 120.00 15 18.00 17.85 0.15 102.00 119.00 0.00 80 102.00 0 0.00 81.60 80.92 0.68
173665 1 20021231 1222003 KPHA 204.40 159.78 1 159.78 161.00 15 24.15 23.97 0.18 136.85 159.78 0.00 80 136.85 0 0.00 109.48 108.65 0.83
175501 1 20030121 2142003 KPHA 65.94 40.61 1 40.61 42.00 15 6.30 6.09 0.21 35.70 40.61 0.00 80 35.70 0 0.00 28.56 27.62 0.94
172494 2 20021213 1102003 KPHA 19.77 22.34 1 22.34 24.00 15 3.60 3.35 0.25 20.40 22.34 0.00 80 20.40 0 0.00 16.32 15.19 1.13
172478 2 20021212 1102003 KPHA 19.77 22.34 1 22.34 24.00 15 3.60 3.35 0.25 20.40 22.34 0.00 80 20.40 0 0.00 16.32 15.19 1.13
172493 2 20021206 1102003 KPHA 19.77 22.34 1 22.34 24.00 15 3.60 3.35 0.25 20.40 22.34 0.00 80 20.40 0 0.00 16.32 15.19 1.13
172587 4 20021213 1102003 KPHA 19.77 22.34 1 22.34 25.00 10 2.50 2.23 0.27 22.50 22.34 0.00 50 22.50 0 0.00 11.25 10.06 1.19
176692 2 20030207 2262003 KPHA 145.82 89.84 1 89.84 92.00 15 13.80 13.48 0.32 78.20 89.84 0.00 80 78.20 0 0.00 62.56 61.09 1.47
174290 1 20021121 1242003 KPHA 76.59 102.78 1 102.78 105.00 15 15.75 15.42 0.33 89.25 102.78 0.00 80 89.25 0 0.00 71.40 69.89 1.51
173724 2 20021230 1222003 KPHA 76.59 102.78 1 102.78 105.00 15 15.75 15.42 0.33 89.25 102.78 0.00 80 89.25 0 0.00 71.40 69.89 1.51
172916 1 20021226 1152003 KPHA 76.59 102.78 1 102.78 105.00 15 15.75 15.42 0.33 89.25 102.78 0.00 80 89.25 0 0.00 71.40 69.89 1.51
172345 1 20021219 1082003 KPHA 76.59 102.78 1 102.78 105.00 15 15.75 15.42 0.33 89.25 102.78 0.00 80 89.25 0 0.00 71.40 69.89 1.51
171963 1 20021219 1082003 KPHA 76.59 102.78 1 102.78 105.00 15 15.75 15.42 0.33 89.25 102.78 0.00 80 89.25 0 0.00 71.40 69.89 1.51
172811 3 20021218 1102003 KPHA 506.27 267.67 1 267.67 270.00 15 40.50 40.15 0.35 229.50 267.67 0.00 80 229.50 0 0.00 183.60 182.02 1.58
175194 4 20030122 2132003 KPHA 506.27 267.67 1 267.67 270.00 15 40.50 40.15 0.35 229.50 267.67 0.00 80 229.50 0 0.00 183.60 182.02 1.58
175604 3 20030124 2142003 KPHA 506.27 267.67 1 267.67 270.00 15 40.50 40.15 0.35 229.50 267.67 0.00 80 229.50 0 0.00 183.60 182.02 1.58
172204 3 20021210 1082003 KPHA 506.27 267.67 1 267.67 270.00 15 40.50 40.15 0.35 229.50 267.67 0.00 80 229.50 0 0.00 183.60 182.02 1.58
176659 3 20030206 2262003 KPHA 506.27 267.67 1 267.67 270.00 15 40.50 40.15 0.35 229.50 267.67 0.00 80 229.50 0 0.00 183.60 182.02 1.58
174027 6 20030103 1222003 KPHA 506.27 267.67 1 267.67 270.00 15 40.50 40.15 0.35 229.50 267.67 0.00 80 229.50 0 0.00 183.60 182.02 1.58
175599 3 20030123 2142003 KPHA 506.27 267.67 1 267.67 270.00 15 40.50 40.15 0.35 229.50 267.67 0.00 80 229.50 0 0.00 183.60 182.02 1.58
Rnf%
t
MCCLM_INE NSX MCBDOS MCPDDT DPPOD CMED97:MEDCUR AYS MEDDAYS MCCLMD CPER\CTDISC:CORDISC:DIFFDISC MCACTALL MCCORALL VICDUCT NPER1 ACTPAID1 ER2 CTPAID2 DTPAIDT;CORPAID)IFFPAID
173053 1 20021121 1152003 KPHA 111.00 148.95 1 148.95 140.00 15 21.00 21.00 0.00 119.00 140.00 0.00 80 119.00 0 0.00 95.20 95.20 0.00
173521 1 20021219 1172003 KPHA 111.00 148.95 1 148.95 140.00 15 21.00 21.00 0.00 119.00 140.00 0.00 80 119.00 0 0.00 95.20 95.20 0.00
175007 1 20030120 2052003 KPHA 111.00 148.95 1 148.95 140.00 15 21.00 21.00 0.00 119.00 140.00 0.00 80 119.00 0 0.00 95.20 95.20 0.00
172528 1 20021216 1102003 KPHA 111.00 148.95 1 148.95 140.00 15 21.00 21.00 0.00 119.00 140.00 0.00 80 119.00 0 0.00 95.20 95.20 0.00
175507 1 20021210 2142003 KPHA 111.00 148.95 1 148.95 120.00 15 18.00 18.00 0.00 102.00 120.00 0.00 80 102.00 0 0.00 81.60 81.60 0.00
172566 1 20021217 1102003 KPHA 111.00 148.95 1 148.95 125.00 15 18.75 18.75 0.00 106.25 125.00 0.00 80 106.25 0 0.00 85.00 85.00 0.00
170796 1 20021119 1082003 KPHA 111.00 148.95 1 148.95 145.00 15 21.75 21.75 0.00 123.25 145.00 0.00 80 123.25 0 0.00 98.60 98.60 0.00
172034 3 20021223 1082003 KPHA 111.00 148.95 1 148.95 129.00 .15 19.35 19.35 0.00 109.65 129.00 0.00 80 109.65 0 0.00 87.72 87.72 0.00
172315 1 20021213 1082003 KPHA 111.00 148.95 1 148.95 135.00 15 20.25 20.25 0.00 114.75 135.00 0.00 100 114.75 0 0.00 114.75 114.75 0.00
173037 1 20021112 1152003 KPHA 111.00 148.95 1 148.95 140.00 15 21.00 21.00 0.00 119.00 140.00 0.00 100 119.00 0 0.00 119.00 119.00 0.00
173886 1 20021216 1222003 KPHA 111.00 148.95 1 148.95 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 100 110.50 0 0.00 110.50 110.50 0.00
171919 1 20021218 1082003 KPHA 111.00 148.95 1 148.95 140.00 15 21.00 21.00 0.00 119.00 140.00 0.00 80 119.00 0 0.00 95.20 95.20 0.00
172367 1 20021212 1082003 KPHA 111.00 148.95 1 148.95 135.00 15 20.25 20.25 0.00 114.75 135.00 0.00 80 114.75 0 0.00 91.80 91.80 0.00
172578 1 20021216 1102003 KPHA 111.00 148.95 1 148.95 125.00 15 18.75 18.75 0.00 106.25 125.00 0.00 80 106.25 0 0.00 85.00 85.00 0.00
174067 1 20021227 1222003 KPHA 111.00 148.95 1 148.95 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
173805 1 20021217 1222003 KPHA 111.00 148.95 1 148.95 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
174066 1 20021227 1222003 KPHA 127.62 179.82 1 179.82 150.00 15 22.50 22.50 0.00 127.50 150.00 0.00 80 127.50 0 0.00 102.00 102.00 0.00
173343 1 20021230 1152003 KPHA 127.62 179.82 1 179.82 159.00 15 23.85 23.85 0.00 135.15 159.00 0.00 80 135.15 0 0.00 108.12 108.12 0.00
172650 1 20021211 1102003 KPHA 127.62 179.82 1 179.82 150.00 15 22.50 22.50 0.00 127.50 150.00 0.00 80 127.50 0 0.00 102.00 102.00 0.00
172168 1 20021211 1082003 KPHA 127.62 179.82 1 179.82 159.00 15 23.85 23.85 0.00 135.15 159.00 0.00 80 135.15 0 0.00 108.12 108.12 0.00
172825 1 20021209 1102003 KPHA 127.62 179.82 1 179.82 140.00 15 21.00 21.00 0.00 119.00 140.00 0.00 100 119.00 0 0.00 119.00 119.00 0.00
171448 1 20021203 1152003 KPHA 127.62 179.82 1 179.82 150.00 15 22.50 22.50 0.00 127.50 150.00 0.00 80 127.50 0 0.00 102.00 102.00 0.00
172287 6 20021213 1082003 KPHA 128.15 179.03 1 179.03 150.00 15 22.50 22.50 0.00 127.50 150.00 0.00 50 127.50 0 0.00 63.75 63.75 0.00
174282 1 20021225 1242003 KPHA 128.26 180.29 1 180.29 170.00 15 25.50 25.50 0.00 144.50 170.00 0.00 80 144.50 0 0.00 115.60 115.60 0.00
174183 2 20021224 1242003 KPHA 128.26 180.29 1 180.29 132.00 15 19.80 19.80 0.00 112.20 132.00 0.00 80 112.20 0 0.00 89.76 89.76 0.00
173350 1 20021209 1152003 KPHA 128.26 180.29 1 180.29 132.00 15 19.80 19.80 0.00 112.20 132.00 0.00 80 112.20 0 0.00 89.76 89.76 0.00
173046 1 20021210 1152003 KPHA 128.54 138.74 1 138.74 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
173047 2 20021209 1152003 KPHA 128.54 138.74 1 138.74 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
171954 1 20020809 1082003 KPHA 128.54 144.98 1 144.98 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
172719 1 20021206 1102003 KPHA 128.54 138.74 1 138.74 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
172025 6 20021216 1082003 KPHA 128.54 138.74 1 138.74 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
172041 1 20021212 1082003 KPHA 128.54 138.74 3 416.22 390.00 15 58.50 58.50 0.00 331.50 390.00 0.00 80 331.50 0 0.00 265.20 265.20 0.00
173573 4 20021224 1172003 KPHA 128.54 138.74 1 138.74 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
172422 1 20021218 1102003 KPHA 128.54 138.74 1 138.74 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 100 110.50 0 0.00 110.50 110.50 0.00
173243 1 20020802 1152003 KPHA 128.54 144.98 1 144.98 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
174505 3 20021223 1292003 KPHA 128.54 138.74 1 138.74 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
174767 1 20030108 1312003 KPHA 128.54 138.74 1 138.74 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
173083 1 20021204 1152003 KPHA 128.54 138.74 1 138.74 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
170710 2 20021112 1082003 KPHA 131.09 250.48 1 250.48 150.00 15 22.50 22.50 0.00 127.50 150.00 0.00 80 127.50 0 0.00 102.00 102.00 0.00
172462 1 20021219 1102003 KPHA 138.73 204.01 1 204.01 165.00 15 24.75 24.75 0.00 140.25 165.00 0.00 80 140.25 0 0.00 112.20 112.20 0.00
172562 1 20021218 1102003 KPHA 151.57 222.90 1 222.90 153.00 15 22.95 22.95 0.00 130.05 153.00 0.00 80 130.05 0 0.00 104.04 104.04 0.00
175577 2 20030108 2142003 KPHA 154.14 177.84 17 • 3023.28 1972.00 15 295.80 295.80 0.00 1676.20 1972.00 0.00 100 1676.20 0 0.00 1676.20 1676.20 0.00
171930 3 20021023 1082003 KPHA 168.04 169.85 2 339.70 260.00 15 39.00 39.00 0.00 221.00 260.00 0.00 100 221.00 0 0.00 221.00 221.00 0.00
171933 5 20021028 1082003 KPHA 168.04 169.85 4 679.40 520.00 15 78.00 78.00 0.00 442.00 520.00 0.00 100 442.00 0 0.00 442.00 442.00 0.00
174505 4 20021223 1292003 KPHA 168.15 181.61 1 181.61 175.00 15 26.25 26.25 0.00 148.75 175.00 0.00 80 148.75 0 0.00 119.00 119.00 0.00
175010 1 20030108 2052003 KPHA 177.60 238.32 1 238.32 205.00 15 30.75 30.75 0.00 174.25 205.00 0.00 80 174.25 0 0.00 139.40 139.40 0.00
172353 1 20021212 1082003 KPHA 177.60 238.32 1 238.32 200.00 15 30.00 30.00 0.00 170.00 200.00 0.00 80 170.00 0 0.00 136.00 136.00 0.00
172212 1 20021216 1082003 KPHA 177.60 238.32 1 238.32 205.00 15 30.75 30.75 0.00 174.25 205.00 0.00 80 174.25 0 0.00 139.40 139.40 0.00
174558 1 20030121 1292003 KPHA 177.60 238.32 1 238.32 210.00 15 31.50 31.50 0.00 178.50 210.00 0.00 80 178.50 0 0.00 142.80 142.80 0.00
173151 1 20021217 1152003 KPHA 177.60 238.32 1 238.32 190.00 15 28.50 28.50 0.00 161.50 190.00 0.00 50 161.50 0 0.00 80.75 80.75 0.00
172915 1 20021226 1152003 KPHA 177.60 238.32 1 238.32 205.00 15 30.75 • 30.75 0.00 174.25 205.00 0.00 100 174.25 0 0.00 174.25 174.25 0.00
174631 1 20020123 1312003 KPHA 182.32 227.68 1 227.68 225.00 15 33.75 33.75 0.00 191.25 225.00 0.00 80 191.25 0 0.00 153.00 153.00 0.00
172640 1 20021216 1102003 KPHA 182.32 256.88 1 256.88 186.30 15 27.95 27.95 0.00 158.35 186.30 0.00 50 158.35 0 0.00 79.18 79.18 0.00
173315 1 20021212 1152003 KPHA 183.76 232.44 1 232.44 200.00 15 30.00 30.00 0.00 170.00 200.00 0.00 80 170.00 0 0.00 136.00 136.00 0.00
174180 2 20021224 1242003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
173320 1 20021207 1152003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
173071 1 20021201 1152003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
174182 1 20021206 1242003 KPHA 193.00 271.29 1 271.29 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
172428 2 20020318 1102003 KPHA 193.00 267.81 1 267.81 199.00 15 29.85 29.85 0.00 169.15 199.00 0.00 80 169.15 0 0.00 135.32 135.32 0.00
Fnf%fl
1
MCCLM JNE NSX MCBDOS MCPDDT CPPOD CMED97;MEDCUR AYS MEDDAYS MCCLMD CPER\CTDISC:CORDISC:DIFFDISC MCACTALL MCCORALL NCDUCT NPER1 ACTPAID1 ER2 CTPAID2::TPAIDT:CORPAID)IFFPAID
172646 1 20021213 1102003 KPHA 76.59 102.78 1 102.78 100.00 15 15.00 15.00 0.00 85.00 100.00 0.00 80 85.00 0 0.00 68.00 68.00 0.00
172108 1 20021209 1082003 KPHA 76.59 102.78 1 102.78 80.00 15 12.00 12.00 0.00 68.00 80.00 0.00 80 68.00 0 0.00 54.40 54.40 0.00
173034 1 20021216 1152003 KPHA 76.59 102.78 1 102.78 80.00 15 12.00 12.00 0.00 68.00 80.00 0.00 80 68.00 0 0.00 54.40 54.40 0.00
173492 1 20021231 1172003 KPHA 76.59 102.78 1 102.78 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
173802 1 20021217 1222003 KPHA 76.59 102.78 1 102.78 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
173735 1 20021220 1222003 KPHA 76.59 102.78 1 102.78 85.00 15 12.75 12.75 0.00 72.25 85.00 0.00 100 72.25 0 0.00 72.25 72.25 0.00
173300 1 20021212 1152003 'KPHA 76.59 102.78 1 102.78 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
172448 1 20021211 1102003 KPHA 76.59 102.78 1 102.78 85.00 15 12.75 12.75 0.00 72.25 85.00 0.00 80 72.25 0 0.00 57.80 57.80 0.00
173946 1 20021219 1222003 KPHA 76.59 102.78 1 102.78 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
172189 1 20021211 1082003 KPHA 76.59 102.78 1 102.78 80.00 15 12.00 12.00 0.00 68.00 80.00 0.00 50 68.00 0 0.00 34.00 34.00 0.00
172336 1 20021213 1082003 KPHA 76.59 102.78 1 102.78 85.00 15 12.75 12.75 0.00 72.25 85.00 0.00 80 72.25 0 0.00 57.80 57.80 0.00
172190 1 20021206 1082003 KPHA 76.59 102.78 1 102.78 80.00 15 12.00 12.00 0.00 68.00 80.00 0.00 50 68.00 0 0.00 34.00 34.00 0.00
172877 1 20021211 1152003 KPHA 76.59 102.78 1 102.78 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
173481 1 20021217 1172003 KPHA 76.59 102.78 1 102.78 95.00 15 14.25 14.25 0.00 80.75 95.00 0.00 80 80.75 0 0.00 64.60 64.60 0.00
173481 2 20021203 1172003 KPHA 76.59 102.78 1 102.78 95.00 15 14.25 14.25 0.00 80.75 95.00 0.00 80 80.75 0 0.00 64.60 64.60 0.00
172447 1 20021119 1102003 KPHA 76.59 102.78 1 102.78 85.00 15 12.75 12.75 0.00 72.25 85.00 0.00 80 72.25 0 0.00 57.80 57.80 0.00
172598 1 20021216 1102003 KPHA 76.59 102.78 1 102.78 100.00 15 15.00 15.00 0.00 85.00 100.00 0.00 80 85.00 0 0.00 68.00 68.00 0.00
172897 1 20021230 1152003 KPHA 76.59 102.78 1 102.78 100.00 15 15.00 15.00 0.00 85.00 100.00 0.00 80 85.00 0 0.00 68.00 68.00 0.00
173078 1 20021221 1152003 KPHA 76.59 102.78 1 102.78 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
172192 1 20021205 1082003 KPHA 76.59 102.78 1 102.78 85.00 15 12.75 12.75 0.00 72.25 85.00 0.00 80 72.25 0 0.00 57.80 57.80 0.00
173050 1 20021111 1152003 KPHA 76.59 102.78 1 102.78 95.00 15 14.25 14.25 0.00 80.75 95.00 0.00 80 80.75 0 0.00 64.60 64.60 0.00
173060 1 20021222 1152003 KPHA 76.59 102.78 1 102.78 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
172939 1 20021219 1152003 KPHA 76.59 102.78 1 102.78 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
171922 1 20021218 1082003 KPHA 76.59 102.78 1 102.78 100.00 15 15.00 15.00 0.00 85.00 100.00 0.00 80 85.00 0 0.00 68.00 68.00 0.00
172727 2 20021126 1102003 KPHA 76.59 102.78 1 102.78 80.00 15 12.00 12.00 0.00 , 68.00 80.00 0.00 80 68.00 0 0.00 54.40 54.40 0.00
172004 1 20021220 1082003 KPHA 76.59 102.78 1 102.78 87.00 15 13.05 13.05 0.00 73.95 87.00 0.00 50 73.95 0 0.00 36.98 36.98 0.00
172558 1 20021216 1102003 KPHA 76.59 102.78 1 102.78 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 100 76.50 0 0.00 76.50 76.50 0.00
173801 1 20021212 1222003 KPHA 76.59 102.78 1 102.78 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 100 76.50 0 0.00 76.50 76.50 0.00
173488 1 20021222 1172003 KPHA 76.59 102.78 1 102.78 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
174913 1 20021119 1312003 KPHA 78.23 118.16 1 118.16 80.00 15 12.00 12.00 0.00 68.00 80.00 0.00 100 68.00 0 0.00 68.00 68.00 0.00
173067 3 20021223 1152003 KPHA 83.34 131.68 1 131.68 129.00 15 19.35 19.35 0.00 109.65 129.00 0.00 80 109.65 0 0.00 87.72 87.72 0.00
171917 1 20021217 1082003 KPHA 83.50 118.17 1 118.17 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 100 76.50 0 0.00 76.50 76.50 0.00
175500 1 20030129 2142003 KPHA 83.50 118.17 1 118.17 90.00 15 13.50 13.50 0.00 76.50 90.00 39.00 80 37.50 0 0.00 30.00 30.00 0.00
172015 1 20021226 1082003 KPHA 83.50 118.17 1 118.17 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
172015 2 20021230 1082003 KPHA 83.50 118.17 1 118.17 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
174198 1 20030116 1242003 KPHA 83.50 118.17 1 118.17 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
172216 1 20021219 1082003 KPHA 83.50 118.17 1 118.17 90.00 15 13.50 13.50 0.00 76.50 90.00 0.00 80 76.50 0 0.00 61.20 61.20 0.00
174038 1 20020416 1222003 KPHA 98.00 122.38 1 122.38 100.00 15 15.00 15.00 0.00 85.00 100.00 0.00 80 85.00 0 0.00 68.00 68.00 0.00
174748 1 20021119 1312003 KPHA 98.00 138.07 1 138.07 110.00 15 16.50 16.50 0.00 93.50 110.00 0.00 80 93.50 0 0.00 74.80 74.80 0.00
172177 1 20021207 1082003 KPHA 98.00 138.07 1 138.07 101.00 15 15.15 15.15 0.00 85.85 101.00 0.00 80 85.85 0 0.00 68.68 68.68 0.00
172014 1 20021219 1082003 KPHA 102.77 145.44 1 145.44 110.00 15 16.50 16.50 0.00 93.50 110.00 0.00 80 93.50 0 0.00 74.80 74.80 0.00
172086 1 20021230 1082003 KPHA 102.77 145.44 1 145.44 110.00 15 16.50 16.50 0.00 93.50 110.00 46.24 80 47.26 0 0.00 37.81 37.81 0.00
174065 1 20021223 1222003 KPHA 107.16 154.14 1 154.14 110.00 15 16.50 16.50 0.00 93.50 110.00 0.00 80 93.50 0 0.00 74.80 74.80 0.00
175002 1 20030114 2052003 KPHA 111.00 148.95 1 148.95 140.00 15 21.00 21.00 0.00 119.00 140.00 0.00 80 119.00 0 0.00 95.20 95.20 0.00
172297 1 20021203 1082003 KPHA 111.00 148.95 1 148.95 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
176254 6 20030123 2192003 KPHA 111.00 148.95 1 148.95 130.00 15 19.50 19.50 0.00 110.50 130.00 76.88 80 33.62 0 0.00 26.90 26.90 0.00
174074 1 20021230 1222003 KPHA 111.00 148.95 1 148.95 130.00 15 19.50 19.50 0.00 110.50 130.00 0.00 80 110.50 0 0.00 88.40 88.40 0.00
171944 1 20021218 1082003 KPHA 111.00 148.95 1 148.95 129.00 15 19.35 19.35 0.00 109.65 129.00 0.00 80 109.65 0 0.00 87.72 87.72 0.00
172530 1 20021212 1102003 KPHA 111.00' 148.95 1 148.95 120.00 15 18.00 18.00 0.00 102.00 120.00 0.00 80 102.00 0 0.00 81.60 81.60 0.00
172525 1 20021211 1102003 KPHA 111.00 148.95 1 148.95 120.00 15 18.00 18.00 0.00 102.00 120.00 0.00 80 102.00 0 0.00 81.60 81.60 0.00
174367 3 20030111 1242003 KPHA 111.00 148.95 1 148.95 120.00 15 18.00 18.00 0.00 102.00 120.00 9.60 80 92.40 0 0.00 73.92 73.92 0.00
172112 1 20021127 1082003 KPHA 111.00 148.95 1 148.95 125.00 15 18.75 18.75 0.00 106.25 125.00 0.00 80 106.25 0 0.00 85.00 85.00 0.00
173440 1 20021210 1172003 KPHA 111.00 148.95 1 148.95 140.00 15 21.00 21.00 0.00 119.00 140.00 0.00 100 119.00 . 0 0.00 119.00 119.00 0.00
172814 1 20021224 1102003 KPHA 111.00 148.95 1 148.95 112.50 15 16.88 16.88 0.00 95.62 112.50 0.00 80 95.62 0 0.00 76.50 76.50 0.00
172298 1 20021217 1082003 KPHA 111.00 148.95 1 148.95 140.00 15 21.00 21.00 0.00 119.00 140.00 0.00 100 119.00 0 0.00 119.00 119.00 0.00
172652 1 20021217 1102003 KPHA 111.00 148.95 1 148.95 140.00 15 21.00 21.00 0.00 119.00 140.00 0.00 80 119.00 0 0.00 95.20 95.20 0.00
172209 1 20021210 1082003 KPHA 111.00 148.95 1 148.95 135.00 15 20.25 20.25 0.00 114.75 135.00 0.00 80 114.75 0 0.00 91.80 91.80 0.00
172639 1 20021216 1102003 KPHA 111.00 148.95 1 148.95 112.50 15 16.88 16.88 0.00 95.62 112.50 0.00 100 95.62 0 0.00 95.62 95.62 0.00
172749 1 20021220 1102003 KPHA 111.00 148.95 1 148.95 112.50 15 16.88 16.88 0.00 95.62 112.50 0.00 80 95.62 0 0.00 76.50 76.50 0.00
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Exhibit H
Claim File Audit Checklist
Monroe County Benefit Plan
Claim File Audit Checklist
March 9, 1998
The following questions are proposed to be incorporated Into a worksheet to be completed for each file reviewed.
The final format has not been completed and will Include items and specific questions added by the County.
1. name of claimant
2. claim number.
3. date of claim:
4. date received at Acordia:
5. type of claim: _in network,_out of network, clinic,_in-hospital, other
6. eligibility verified yes no
7. claimant class: employee, dependent, active, retiree
- • 8. precertified? yes no
9. required to be pre-certified? yes no
10. physician or provider verified? yes no
11. name of treating physician or provider
12.was claim referred from edits? yes no 20. coinsurance applied? yes no
13. diagnosis code verified? yes_ no 21. stop-loss applicable? yes no
14. diagnosis code accepted? yes_ no 22.stop-loss Insurer notified? yes_ no
15.treatment match diagnosis code? yes no 23. any pending items? yes no
16. physician IDA&address verified? yes^_ no 24. pended Items resolved timely? yes_ no
17.charges within UCR? yes_ no 25. claim referred for case management? yes_ no
18. deductible applied? yes no 26. coordination of benefits verified? yes no
19. coinsurance applied? yes no 27.complaint filed? yes_ no_
28. time to pay claim (#of days
COMMENTS:
•
date reviewed: initials:
gao
• _ate.-,__,a...__ «, .... . .. - -a
Exhibit I
Exclusion for Out-of-Network
Services
02/17/2003 12:13 FAX 304 353 8759 ACORDIA NATIONAL • l ]009
-9g OP MOlst �= COUNTY 3( 295-4301 p _ •
Jan-1 ,1'
�,. BOAIkli OF COUNTY (;()MMISS((tN
MAYOR Wilhelmina Ilnrvcy, Disti•icr l
:,�• c.-- Mayor Pro-tcm Shirley Freeman.Uistric(3
-, �_ �'� Gcor a Neu �nl,District 2
o. . ter....--_ R g'
OUNTY O MON ROE —. (.0 _ . Nora Williams,pisiricl 4
ri tcpvw6sr Fu�Htun aamn _ p,.. . . -Mary Kay Reich,Dislriel 5
iium kesuurces Dcrartrnenl - e t( .� ��� ,t om
Ce of the Director ��'9�S
/5100 Colicgc Road, Room 208 �� -.sr flflR'E
o ss; _i �' �n
• > Key Wcst Florida 333040 �•'4 • '�'• • , < '
Phone(305)292-4462 \� .
' Facsimile 30 295-4301 .• fi'' '� '
."
% • F• .
January 20, 19()9 Via Facsimile
Lora Denny
Account Rcpresbnlative
Acordia National
Re: Exclusion for Out-of-Network Services
Dear Ms. Denny,
It has come to our attention that some services within the network Ilealth Care Facilities and
Physician's Offices are provided by out-of-network providers. TJse of these services arc
beyond the patient's control.
After careful consideration, we would like to suggest that the lulluwing services be paid as
though they were in network may if provided by/or in au in-network Health Care facility
or an in-network physician.
• Laboratory and/or Pathology Services
We hope this will help clarify and solve some of the claims problems which have occurred
since the implementation of the benefit reduction for out-of-network providers.
• If you have any questions or wish to discuss this matter further, please do not hesitate to
contact myself or Leah Marquess, Group Insurance Administrator, at (305) 292-4448. •
•
Sin ely,
• Sheila A. Harker
Sr_ I luinan Resources Director
cc: litnilio Monlr
Meytan Luwc-Waticr
Exhibit J
Letter from Lower Keys Medical
Center On KPHA's Contractual
Obligation To Monroe County
Sr
•
LK ® MEDICAL CENTER •
Lower Keys
October 25,2002
Mr. Danny Kohlage
Clerk of the Court
500 Whitehead Street
Key West, Florida 33040
Dear Mr. Kohlage:
You office requested the last 3 years of financials from the KPHA as part of an audit
being conducted by your office. Our attorneys had advised that we are not contractually
obligated to provide the KPHA financials to your office in connection with this audit.
However, we have always enjoyed an excellent relationship with the County and to that
end,please find the requested materials enclosed.
We look forward to maintaining our excellent relationship with the County, therefore
further requests for audit information should be directed to our office in writing, outlining
a description of the scope of the audit and the specific materials requested.
If I can be of any further assistance,please fell free to contact me directly.
Sincerely,
Stephen Kra I en,D.•.
President
SK/mlw
CC: James Roberts, County Administrator
•
•
5900 College Road ` dePoo Building
P.O.Box 9107 1200 Kennedy Drive
Key West, FL 33041-9107 Key West, FL 33040
Ph. 305-294-5531 Ph. 305-294-5531
Fax 305-294-8065 Fax 305-294-8844
Exhibit K
Letter From Executive Director
On Return Of Organization
Exempt From Income Tax
•
\\\ I .
LK _
MEDICAL CENTER
•
Lower Keys
December 2,2002
Sandra L. Mathena, CGFO, CFE, CPA
Director of Internal Audit
Monroe County Circuit Court, Clerk's Office
Monroe County Courthouse 6
500 Whitehead Street, Suite 101
Key West, Florida 33040
Re: Lower Florida Keys Physician/Hospital Organization,Inc.
Dear Ms. Mathena:
I am responding to your November 12, 2002 letter requesting copies of Internal Revenue
Service Form 990's (Return of Organization Exempt from Income Tax) and other
corporate documents for Lower Florida Keys Physician/Hospital Organization, Inc.
("PHO") as part of the County's audit. Please note that although the PHO was organized
as a Florida not-for-profit corporation, the PHO is not a tax-exempt entity and has never
applied for tax-exempt status from either the federal government or the State of Florida.
Therefore, the PHO cannot comply with your request for copies of any applications for
tax exemption or Form-990's for the past three'years. With respect to your additional
request for corporate records, enclosed please find a copy of the PHO's Articles of
Incorporation for your review.
If I can be of any further assistance,please feel free to contact me directly.
• cerely, •
onald L. Bierman,
Executive Director
•
5900 College Road dePoo Building
P.O.Box 9107 1200 Kennedy Drive
Key West, FL 33041-9107 Key West, FL 33040
Ph. 305-294-5531 Ph. 305-294-5531
Fax 305-294-8065 Fax 305-294-8844
r—,
-
MEMORANDUM
Date: Monday, May 19, 2003
To: Danny Kolhage ; eir,
From: James L. Roberts
County Administrator
Subject: Draft Preliminary Audit Review of Monroe County Health Benefits Program
•We asked the Audit Department to forward via email their report so we could enter the
responses directly into the report. R;The,.Lotus..Spread'Sheets that were'eembedded_ in'the
reports did not,translate in:our system and;there is a notation to that effect wherever those
spread sheets would have appeared.
In order to put this audit in perspective, data was reviewed for the years 2000, 2001 and
2003. The number of claims processed by Acordia for the same periods was 28,523,32,742
and 32,533.
Under Background Information it states that the County established a self-insurance
program effective July 1, 1996. That was the date when we entered into arrangements
with the KPHA and Acorida. The county actually began being self insured for Medical in
1984.
In response to the Preliminary Draft Audit, the County Administrator's responses to the
Findings are as follows:
A. Third Party Administrator's Calculation of Payments to Providers
The auditors tested 971 claims paid in November 2002. Total paid claims for November
2002 were $1,119,946.04. Numerous problems were found within the test data. The
breakdown of the claims in the test data is as follows:
1. Prompt Pay Discounts -In Network KPHA
Finding: The auditors tested 971 claims paid ($298,497.08 dollars tested) in November.
2002 of which 546 claims ($144,055.63) or 48.3% were in the KPHA network to
determine if the claims were properly paid. Several problems were found with the •
calculations. Prompt pay discounts of 15% were applied to total billed charges by
1 -
VII. AUDITEE RESPONSES
BOARD OF COUNTY COMMISSIONERS
COUNTY o M O N ROE 1;1 Mayor Dixie M. Spehar,District I
KEY WEST FLORIDA 33040 �y
.; ��� Mayor Pro Tern Murray E.Nelson,District 5
305 294-4641 �YG.;i Charles"Sonny"McCoy,District 3
Management Services Division j; r George Neugent,District 2 •
g ��:41, ,.. �- David Rice,District 4
1100 Simonton • `.� .,, „ • ,;
Key West , FL 33040
(305) 292-4537
MEMORANDUM
Date: Thursday, May 22, 2003
To: Danny Kolhage
From: James L. Roberts
County Administrator
Subject: Memorandum dated May 19, 2003 regarding Draft Audit Review of Monroe
County Health Benefits Program
This is to acknowledge receipt of the Lotus spread sheets in the hard copy of the above-
referenced draft audit. They were omitted in the above response because they did not translate
in our system.
1
Acordia National. This 15% discount is then subtracted from total billed charges and
the net amount is then compared to Medicode's 90th percentile. According to Acordia,
if this net amount exceeds the amount for the 90th percentile of the particular CPT
code the difference will be disallowed and neither the County nor the employee is
responsible for payment. However, of the 971 claims tested for November 2002, there
were no claims for in county providers that were reduced to the 90th percentile of
Medicode. According to.the Agreement and the intention of the plan, the third party
administrator should first compare the billed charge to the 90th percentile of Medicode,
reduce it if necessary to the 90th percentile and then the 15% prompt pay discount is
applied. See Exhibit D - KPHA Letter Defining Contract Prompt Pay Discount. The
contract states the following:
Provider Reimbursement Terms: KPHA shall use best efforts to ensure that the
Participating Provider's physician Usual Customary and Reasonable (UCR)
charges will not change during the term of one year. Thereafter, KPHA agrees to
provide a ninety (90) day notification in the event of a charge increase. Physician
UCR charges will be based upon "the Medicode database." The above agreed
upon discount will be applied to the billed charge, not to exceed the UCR charge
for a service.
Participating Provider Compensation: All claims for covered services, whether
payable by the Employer or a Covered Person will receive a discount off of
provider billed charges as specified in Attachment A. This discount will be
rescinded if an appropriately documented and non-contested claim is not paid to
the Participating Provider within thirty (30) days of being received by the claims
administrator(Acordia National).
The following claim payment example demonstrates the difference between Acordia's
actual method of payment using the 1997 Medicode Fee Schedule and the correct
method of payment according to the agreement and intention of the plan:
Note: Clerk's Lotus Spreadsheet did not transfer in document conversion.
The amount overpaid to the provider for this claim is $88.13. Overpayment by the
County is $70.50 and overpayment by the employee is $17.63 using the above
example. See Exhibit E -Acordia Explanation of Benefits.
Acordia National is also using a Medicode Fee Schedule that is six years old. See Finding
- A-2 1997 Medicode Fee Schedule Used For Comparison of Reasonable and
Customary Charges.
Acordia's method of calculating the 15% prompt pay discount results in the County not
receiving a prompt pay discount from physicians charging at or above the 90th
percentile of Medicode's usual and customary charges. During the audit, it was
discovered that initially Acordia was calculating the discount correctly according to the
2
County and KPHA's interpretation. Acordia's preliminary schedule of overpayment is
as follows:
Note: Clerk's Lotus Spreadsheet did not transfer in document conversion
Acordia's management produced computer reports to determine the extent of the
overpayment. From analysis of claims processed in previous years, it appears that in
2001 Acordia began calculating the claims incorrectly.
Recommendation(s):
1. Group Insurance Management should ensure that Acordia National calculates
prompt pay discounts according to the terms of the KPHA Proposal and
Agreement.
County Administrator's Response:
Management agrees with recommendation. Although questions were raised about
the ever increasing costs, full, detailed information has not been available. We
obtained the basic information through another channel. Senior Management for
Management Services requested a comparison between Medicode and another
Code, Health Insurance Association of America, to see if a cost reduction could be
obtained. It could not. However, the information received allowed the Auditors
to investigate the proper handling of claims under Medicode. Acordia has been
advised by both KPHA and Monroe County of the proper handling of claims
under Medicode. (See attached letters)
2. 1997 Medicode Fee Schedule Used For Comparison of Reasonable and Customary
Charges
Finding:
Acordia National processes physician claims for the KPHA Network using the 90th
percentile of the 1997 Medicode Fee Schedule for the usual and customary
comparison. See Exhibit F - KPHA Network Payments Memo. According to Richard
Legg, Sr. VP/COO., at Acordia National "We take the total charge and multiply it by
15%, and then compare it with the 1997 Medicode Fee Schedule that is loaded in our
system and allow the lesser amount of the two." He further states "In addition, we
have had several providers that have questioned the old fee schedule and have
informed us that their contract says it is a 15% discount, so we have used this figure
rather than the fee schedule, once again because it is over 6 years old."
Acordia stated that they have informed KPHA numerous times that the fee schedule is
outdated. KPHA is receiving the updates from the software company and stated that
their software company is supposed to send updates directly to Acordia. County
Management meets with Acordia National and KPHA personnel on a monthly basis to
3
discuss the plan and was never advised by Acordia or KPHA there was a problem with
the fee schedule.
The proposal submitted by KPHA states the following:
In County Network Providers: The in county network providers are reimbursed at a
usual and customary charge rate as established by "Medicode," a company that
established standard charges for all procedures and services. Monitoring for
compliance with these charges is a function of the third party administrator and •
the Plan's Case Management Services. Providers will accept charges by these
standards as total compensation for services. In-County providers also provide a
prompt payment program. This program provides for a prompt payment discount
(PPD) of fifteen percent (15%) from billed charges if payment is received from
payor within 30 days from date of submission of a clean claim.
Based on the 1997 fee schedule and method Acordia was using to determine reasonable
and customary charges for our test month Acordia overpaid $6,010.64 on 71 claims,
using an updated Medicode Fee Schedule Acordia overpaid $5,104.80. After
discussions-of certain claims with Internal Audit, Acordia states "Due to complexities
with this old fee schedule, we have discovered that we have used the 15% discount in
situations where we should have used the fee schedule. We are reviewing this to see if
adjustments to some claims need to be done." See Exhibit G - Acordia's Preliminary
2002 Schedule of Overpayments.
If an updated Medicode Fee Schedule (November 2002) had been used for the example
from the previous finding the overpayment would be $24.75, $19.80 overpaid by the
County and$4.95 overpaid by the employee.
Note: Clerk's Lotus Spreadsheet did not transfer in document conversion
Recommendation(s):
1. Group Insurance Management should ensure that the contract defines responsibility
for providing the Medicode usual and customary database and monitor the contract.
2. Group Insurance Management should coordinate the refund process with Acordia.
County Administrator's Response:
Management agrees with recommendation and will propose contract amendments
regarding updating of code and will seek a resolution to overpayments.
3. KPHA Providers Added to Acordia's System Incorrectly
4
Finding:
Five providers were added to Acordia's system incorrectly. Of the five, four of the
providers were KPHA and added to Acordia's system with incorrect discounts or
without a discount. The pathologist was a Dimension provider, but was entered into
Acordia's system as a KPHA provider erroneously.
Note: Clerk's Lotus Spreadsheet did not transfer in document conversion
The discount affects both the amount paid by the County and the employee and it would
also reduce the amount that accumulates toward the employees' deductible.- Acordia
has corrected the KPHA provider discounts to 15% for future payments after
discussions with internal audit.
Incorrect payments would have continued indefinitely since the set-up did not contain
accurate information. Acordia should furnish KPHA a provider listing with tax
identification numbers and discount percentages allowed to review and correct on
a periodic basis.
Recommendation(s):
•
1. Group Insurance Management should coordinate the adjustment process with the
third party administrator.
County Administrator's Response:
Although it was not part of the formal recommendation, Management will request
Acordia furnish a provider listing with tax identification numbers to KPHA on a
periodic basis to review and correct (if necessary) discount percentages.
Management will seek resolution for claims processed with incorrect discount.
4. Claims Paid For Two Ineligible Providers
Claims were erroneously paid for two nurse practitioners. Nurse practitioners are not
listed in the summary plan description (plan booklet) as covered providers. One of the
nurse practitioners billed 30 claims totaling $2,963.00 from September 13, 2001
through February 6, 2003 and the third party administrator paid $648.72. The second
nurse practitioner billed 19 claims totaling $2,132.00 from October 29, 2001 through
March 12, 2003 and the third party administrator paid $733.51. Some of the claims
were paid and others were denied with the EOB explanation stating it was an ineligible
provider. Since nurse practitioners are not covered by the plan, Acordia is processing
refund requests for those items paid in error. The two providers are members of the
KPHA network and they are listed in the KPHA provider listing. If the plan intends to
cover these providers in the future, the plan document should be amended.
5 -
Recommendation(s):
1. Group Insurance Management should coordinate the adjustment process with the
third party administrator.
County Administrator's Response:
Management has been approached by KPHA to add Nurse Practitioners as covered
providers under the plan. They can be added at the next plan document
change. Management will seek resolution for incorrect processing of providers.
5. Providers in Both KPHA and Dimension Networks Paid Using Smaller Discount
Finding:
During the examination of claims, it was determined that three providers belong to both the
Dimension Network and the KPHA Network. The claims of these three providers were
paid using the Dimension discount of 10% rather than the larger KPHA discount of
15%. The total claims paid in the test period for the three providers was $2,670.
Acordia is producing reports to indicate the amounts paid using the smaller Dimension
discount.
Acordia's Management stated that they can not just take the largest discount because the
Claims Examiner would have to process the claim twice. Acordia needs to be
instructed which network to use if a provider is a member of both. For these three
providers the Dimension discount is lower and the KPHA discount should have been
used. Group Insurance Management should inquire of Acordia if they can make
changes to their system so the highest network discount is used to process the claim.
However, if Acordia is unable to automate this function, Group Insurance Management
should research and instruct Acordia on which network to use as the first priority.
However, this priority should be monitored as discounts change within the networks
(originally KPHA's discount was 5% and then increased to 15% for physicians and
25% for hospitals). For example, Dimension offered a 16% discount at Baptist,
according to Interisk's Audit of Medical Benefit Claim Administration May 1998, and
now the discount has been reduced to 10%. The new Multiplan network should also be
considered when Group Insurance Management sets the priority of which network to
use. A specific procedure to determine which discount applies will assist Acordia in •
properly adjusting claims as well as reduce the overall claim payment amount.
Recommendation(s):
1. Group Insurance Management should establish a written procedure for applying
discounts where providers are members of multiple networks.
6
2. Group Insurance Management should establish a program of audits and inquiries on a
periodic basis to ensure that the plan is functioning as intended.
County Administrator's Response:
Management has been told by KPHA on several occasions that when a provider was a
member of multiple networks, the claims were processed using the network that
gave the greater discount. Recently Acordia stated that this cannot be done.
Management will request an additional attempt to have this programmed into
their process. If this change can not be made, direction would be to use KPHA
for Monroe County providers, Dimension for providers in Miami-Dade, Broward
& Palm Beach Counties, and Multi-Plan for all other locations.
The Multi-Claim Lease Agreement (when completed) will allow on-line access to
Acordia information and facilitate doing audits of this activity.
6. Miscellaneous Errors
Finding:
A review of physician bills related to the audit sample revealed the following
miscellaneous problems:
One dental claim #23853 for a fluoride treatment for a child (procedure code 01203) was
billed at $26.00, but the claim was incorrectly calculated by the Claims Examiner and
paid at$260. A refund was requested during the audit.
On one outpatient hospital bill totaling $264.20 the 25% discount was not taken due to the
Claims Examiner erroneously applying a manual override. A refund of $66.05 was
requested during the audit.
Recommendation(s):
1. Group Insurance Management should establish a,program of audits and inquiries on a
periodic basis to ensure that the plan is functioning as intended.
2. Group Insurance Management should coordinate the adjustment process with the
third party administrator.
County Administrator's Response:
Management will seek resolution to the adjustment process. The nature of the
above claims that were processed incorrectly was not through a fault of the
system, but human error. Hopefully with periodic audits by the Group Insurance
Management, the likelihood of future errors will be decreased. The County's
insurance consultant will assist in devising a program of audits and inquiries.
7
B. Monitoring
1. Monitoring Of Claims Not Implemented
Finding:
The initial plan with direct submission of claims included the Group Insurance Department
doing random claims inquiry. According to Interisk's Audit of Medical Benefit Claim
Administration May 1998, Acordia would provide the needed software adjustments to
permit full access to the same computer records that Acordia claim examiners use.
With full access to computer information and the ability to print out individual records,
the County can perform a random continuous audit on a weekly basis. Group
Insurance also receives a copy of the explanation of benefits. Internal Audit reviewed
explanation of benefits for proper discounts, deductibles, and that charges were
reduced to 90% of Medicode before the discount was applied. The Internal Audit
Department provided Group Insurance with a spreadsheet that was used in the audit to
detect payments that were incorrectly calculated. Group Insurance might consider
adding some of the questions used by Interisk in the claim file audit checklist in the
monitoring- process. See Exhibit H - Claim Worksheet and Claim File Audit
Checklist. The actual physician bill can be requested if a payment appears
questionable for any reason. Errors detected can be corrected by Acordia more quickly
and recovery of any claims paid in error may be more likely.
The Internal Audit Review of Monroe County Group Health Insurance completed June
1998 recommended that a program of random audits and inquiries should be
established on a periodic basis to ensure that the plan is functioning as intended and to
control any risk of fraud. The random audits and inquiries were not implemented by
County Management.
Recommendation(s):
1. Group Insurance Management should require Acordia National to provide remote
access to all claim software and claim detail files and all necessary training.
2. Group Insurance Management should establish a program of audits and inquiries on a
weekly basis to ensure that the plan is functioning as intended:
County Administrator's Response:
The Board of County Commissioners has approved a Multi-Claim Lease Agreement
that is currently being executed. This will provide access to do random audits
and inquiries on claims processed. These audits will begin as soon as lease is
fully processed. This should address the above recommendations. The County's
insurance consultant will assist in devising a program of audits and inquiries.
2. Written Confirmation of Changes
8
Finding:
Group Insurance had given written instructions to Acordia and to KPHA to make many
changes that are findings in the current audit report. For example, Group Insurance
Management asked numerous times at meetings if the Medicode was current and was
never told that there was a problem. Acordia was using version that was six years old.
Medicode should have been updated with new releases twice each year.
When the change was made for the KPHA providers to grant a 15% discount, the change
should have been implemented October 1, 2000, but it was not updated until October
22, 2000. Another problem occurs with providers that are in more than one network.
Monroe County had instructed Acordia to always take the largest discount. However,
it was not until a February 2003 meeting that Acordia Management indicated that
Group Insurance has to specify which network takes priority. Acordia's computer
system would have to process the claim twice in order to take the largest discount.
Acordia Management claims they do know always receive changes from Group Insurance
or the Networks. Due to the confusion surrounding how Acordia was processing some
of the health claims and to enhance communication and documentation, Group
Insurance Management should send written documentation to Acordia of any changes
to be made and require written confirmation of the date the changes were implemented
and be signed by a representative from Acordia.
Recommendation(s):
1. Group Insurance Management should consider including an acknowledgment form to
be signed by Acordia Management that states the required change was made and the
date it was implemented.
County Administrator's Response:
Management concurs with the above recommendation and will implement with
further plan changes and/or processing revisions.
C. Provider Claims Paid as Out of Network Claims
1. KPIIA Provider Claims Paid as Out of Network Claims
Finding:
Two KPHA providers are billing with more than one federal tax identification number.
One provider billed 74 claims totaling $23,989 and the third party administrator paid
$12,384.14. The second provider billed 462 claims totaling $140,804 and the third
party administrator paid $79,980.46. The claims were paid as out of network claims
(70% coinsurance percentage and no discount) because the tax identification number
did not match the one provided to Acordia by KPHA. According to Acordia
9
Management, this is a common issue for all networks. Providers don't always notify
the networks when their tax identification numbers change and it ultimately results in
claims being paid out of network. A provider can only be matched to a specific
network if they bill their claims with the tax identification number provided to Acordia
by the network. However, in at least one situation, KPHA had notified Acordia on
August 31, 2001 of the correct tax identification number to be used. KPHA plans to
provide both social security numbers and tax identification numbers to Acordia to
update their claim system for all KPHA providers.
Recommendation(s):
1. Group Insurance Management should establish a program of audits and inquiries on
a periodic basis to ensure that the plan is functioning as intended.
County Administrator's Response:
The implementation of the Multi-Claim Lease Agreement will allow Group Insurance
Management to audit the processing to find these errors. Acordia will also be
required to do periodic sorts of the providers to help eliminate the errors that are
outlined above. The County's insurance consultant will assist in devising a
program of audits and inquiries.
2. Dimension Provider Claims Paid as Referrals
Finding:
Numerous Dimension provider claims are paid as referrals, but the providers are actually
participants in the Dimension Network. Providers paid as referrals are paid at the in
network rate of 80% or 100%. A laboratory that joined the Dimension Network on
January 1, 1999 had 783 claims totaling $118,963.62 processed as referrals and the
claims should have been paid based on the Dimension Fee Schedule. For example, one
procedure code (80055) had a charge of $363.26 and Acordia paid $174.40. The
Dimension Fee Schedule amount was $62.35. Therefore, Acordia should have only
paid $49.88 (80% of$62.35). The overpayment for Monroe County's 80% portion on
this one CPT code was $112.05. A claim should only be processed as a referral if it is
not a network provider. In a letter dated January 20, 1999, RE: Exclusion of Out of
Network Services, Group Insurance Management states "We would like to suggest that
the following services be paid as though they were in network only if provided by/or in
an in-network Health Care Facility or an in-network physician - Laboratory and/or
Pathology Services". See Exhibit I - Exclusion for Out-of-Network Services. A list of
other Dimension providers processed as referrals or out of network claims has been
provided to Acordia for correction.
10
Recommendation(s):
1. Group Insurance Management should establish a program of audits and inquiries on
a periodic basis to ensure that the plan is functioning as intended.
2. Group Insurance Management should consider notifying Acordia that the exclusion
no longer applies since the County has three participating networks.
County Administrator's Response:
Management believes claims should always be processed as network provider and if
no network shows up, the system should check for referral before decision to assess
penalty. The referrals are general lab tests and the quantity of them should not be
prohibitive for checking. The referral status is on the claim form and will be required by
Acordia to prevent this problem in the future. The County's insurance consultant will
assist in devising a program of audits and inquiries
D. Certain Dimension Claims are Paid Over Usual and Customary
Finding:
The Employee Benefit Plan Document states in Section 9 - Medical Exclusions (20) that
no payment will be made under this Plan in any event for charges which exceed
reasonable and customary. Reasonable and Customary is defined in Section 12 -
Definitions, as follows:
Section 12 - Definitions Reasonable and Customary: the charge made by a Physician
or supplier of services, medicines, or supplies which does not exceed the general
level of charges made by others rendering or furnishing like services, medicines,
or supplies, within the area in which the charge is incurred for sickness or injury
comparable in severity and nature to the sickness or injury being treated. The
term area, as it would apply to any particular service, medicine, or supply means a
county or such greater area as is necessary to obtain a representative cross-section
of level of charges.
Some contracts with Dimension providers are based on a straight percentage discount off
of billed charges and other Dimension contracts have a fee_schedule allowed for each
procedure code. The auditors tested 971 claims paid ($298,497.08 dollars tested) in
November 2002 of which 126 claims ($45,358.62) or 15.2% were in the Dimension
network to determine if the claims were properly paid. There were 12 Dimension
claims totaling $8,764.06 which were paid over usual and customary charges in the
test. The total amount paid over the 90th percentile of Ingenix was $2,629.97. KPHA
established the use of the 90th percentile of Medicode to determine reasonable and
customary for their providers before the prompt pay discount is applied. Out of
network claims are compared to the Ingenix fee schedule provided by Acordia and
charges are reduced if the Ingenix amount is lower. The Dimension contracts that are
based on a straight percentage off of billed charges are not compared to any reasonable
11 -
and customary fee schedule. This results in the County paying more with a 10%
discount given by the provider than if the employee had used an out of network
physician. For example, on one of the 12 claims over usual and customary the
Dimension provider billed for $1,698.56 for 4 units of procedure code 88305, the
Ingenix 90th percentile would have allowed $600 for 4 units. The County's 80%
portion to pay would have been $480 and the County actually paid $1,528.72.
Interviews with Dimension personnel revealed that the problem with the flat
percentage is mainly with physicians located in Monroe County because it is a small
negotiated provider discount and it is not compared to any reasonable and customary
fee schedule.
Recommendation(s):
1. Group Insurance Management should discuss with Dimension the problems
identified in the audit and a proposal to correct this deficiency in the future.
County Administrator's Response:
Dimension Health physicians are contracted to work under a fee schedule. However,
this is not the case for doctors contracted by Dimension in Monroe County
(mostly upper keys), where the Dimension contract calls for a discount off of
charges. In the case of those doctors, the discount is off their normal charges and
the Dimension contract does not have the provision where the charges can be
compared to a fee schedule. The terms of the Dimension contract with these
doctors are what determine how they are paid.
Dimension will be asked to go back to these doctors and try to re-contract with
them, with the new contact including a fee schedule cap. At that point, Acordia
could implement the same arrangement currently in place with KPHA
physicians.
E. Maintaining Eligible Member Records
1. County Entities and Departments Not Reporting Employee Changes Timely
Finding:
A review of employee eligibility within the Monroe County Group Insurance Office
identified employing County entities and departments are not always reporting
employee changes on a timely basis. Group Insurance personnel are responsible for
maintaining the eligibility records and they rely on the County entities and departments
to report employee terminations, leave of absences, new hires, retirements and
dependent information with
h the corresponding effective date. A sample test of
terminations entered in Acordia's system by Group Insurance personnel ranged from
11 days prior to termination and up to 60 days after termination.
12
Failure of the County entities and departments to communicate employee changes to
Group Insurance in a timely manner can result in overpayment of benefits for ineligible
employees and their dependents. An interview with Group Insurance personnel
indicated the Sheriff's Department, Social Services and Mosquito Control have had
trouble in the past reporting changes timely. Group Insurance notified the entities
through memos of the necessary requirements to report employee changes. This has
improved the reporting of employee changes. However, due to the large number of
participants and numerous employers and departments within the plan, all County
entities and departments would benefit from documentation of the eligibility •
notification procedures.
Recommendation(s):
1. Group Insurance Management should establish and implement an Administrative
Instruction to provide guidelines regarding procedures on notification requirements
and the responsibility of County departments and entities for employee
terminations, leave of absences, new hires, dependent eligibility and retirements.
County Administrator's Response:
Many of the entities covered under the group health program do not come under the
responsibility of the County Administrator; therefore they would not be covered
under Administrative Instructions. Management will periodically remind the
various entities and departments of the need for prompt notification of any
terminations, retirements, etc. Others will be developed for a procedure for
reminding the various entities of the importance of prompt reporting of payroll
changes and also to cover the correct procedure for BOCC employees.
2. Terminated Employees and Dependents Listed As Active On Acordia
Employee/Dependent File Listing
Finding:
To ensure claims paid were for eligible participants, the auditors compared the Acordia
Employee/Dependent File Listing dated January 2, 2003 to the December 2002 Group
Insurance Billing and the November 2002 Employer Listings. Five terminated
employees were listed as active on the January 2, 2003 Acordia Employee/Dependent
File Listing. In addition, one dependent was listed as active but should have been
deleted from dependent coverage.
Group Insurance personnel fax each employee change or termination to Acordia because
the system access available to them for Acordia is too slow. According to Interisk's
Audit of Medical Benefit Claim Administration May 1998, Acordia would provide the
needed software adjustments to permit full access to the same computer records that
Acordia claim examiners use. Full access to Acordia's system was not implemented.
13 -
Group Insurance should enter all employee activity directly into Acordia's claim system.
Maintaining an accurate and up-to-date list of eligible members of the Health Plan is
essential to ensure that benefits are allowed only for eligible individuals.
Recommendation(s):
1. Group Insurance Management should require Acordia National to provide remote
access to all claim software and claim detail files and all necessary training.
2. Group Insurance Management should enter all employee activity directly into
Acordia's claim system and monitor the Employee/Dependent File Listing for all
the changes made.
County Administrator's Response:
Management believes the Multi-Claims Lease Agreement will allow these
recommendations to be implemented.
F. Agreements
1. Right to Audit Clause in Employer-Provided Network and Utilization Review and
Case Management Services Agreement
Finding:
The Employer-Provided Network and Utilization Review and Case Management Services
Agreement is between Keys Physician-Hospital Alliance and the Monroe County
Board of County Commissioners. The right to audit clause in the contract allows
Acordia (the third party administrator) the right to audit but does not allow the County
access to KPHA's records. The contract states "KPHA shall make available to claims
administrator (Acordia National) all records and other data relating to both the network
and utilization and case management services for the purpose of periodic audits of
KPHA's services. Information/data will be maintained, as required, to assure
confidentiality and compliance with all applicable regulations." As part of our
standard audit procedures, we requested KPHA's financial statements. At first KPHA
refused to allow us access to the financial records. After discussion, KPHA sent us
their financial statements, but not the related trial balance as well as a letter stating their
attorney's opinion that our•contract does not allow the County access. See Exhibit J -
Letter from Lower Keys Medical Center on KPHA's Contractual Obligation to Monroe
County.
All Monroe County agreements should include a right to audit clause in order for the
Internal Audit Department to properly monitor the effectiveness of the contract.
Recommendation:
14
1. Group Insurance Management should include a right to audit clause for the County
in the Agreement with KPHA.
County Administrator's Response:
Management agrees with recommendation and will include in all future agreements.
2. Usual and Customary Reimbursed at 90% of Medicode
Finding:
The In County network providers are reimbursed at a maximum of the usual and
customary charge rate of the 90th percentile of Medicode. Medicode is a healthcare
information company that provides physician charge data. The usual and customary
charges used for reimbursement are geographic and zip code specific. Medicode's
Customized Fee Analyzer cross references CPT (procedural) codes to different
percentiles of the specified area's prevailing fees and to average national allowables
paid by indemnity carriers. Interisk, Inc., (insurance consultant) states that the current
trend is toward using lower percentiles of usual and customary charges. For example,
most of Interisk's customers are using between 80% to 85% of usual and customary
rate schedules.
Percentiles are frequently misunderstood. Based on Medicode's methodology and
databases, if your fee for a given service is at the 90th percentile, only 10% of the
submitted charges for that service are higher than your fee. Medicode's Customized
Fee Analyzer states the following about the 95th percentile "This figure is included so
that health care professionals can see as complete a picture as possible, but it is often
inadvisable to bill at this level. In the current political atmosphere of cost containment,
consistent high level billing can be harmful to the financial well-being of your
practice."
Group Insurance Management should consult with KPHA and Interisk regarding the
consequence of using a lower level of usual and customary reimbursement versus the
current 90% level, which may lower the cost of the plan.
Recommendation(s):
1. Group Insurance Management should consider renegotiating the percentage of
Medicode used for the reasonable and customary rate schedule.
County Administrator's Response:
Management agrees with the recommendation and will pursue a lower percentage of
Medicode.
15
G. Utilization Review
1. Independence
Finding:
As part of our standard audit procedures, we requested KPHA's Form 990 Return of
Organization Exempt from income tax. An organization's completed Form 990 is
available for public inspection as required by Section 6104 of the Internal Revenue
Code. Lower Florida Keys Physician/Hospital Organization, Inc., is organized as a
Florida not-for-profit corporation doing business as Keys Physician-Hospital Alliance.
KPHA has always maintained the independence of their organization by stating that it
is not part of the hospital, they are a separate organization with a separate board of
directors.
Form 990 was not submitted as requested. The Executive Director of KPHA states "Please
note that although the PHO was organized as a Florida not-for-profit corporation, the
PHO is not a tax exempt entity and has never applied for tax-exempt status from either
the Federal Government or the State of Florida. Therefore, the PHO cannot comply
with your request for copies of any application for tax exemption or Form 990's for the
past three years." See Exhibit K - Letter from Executive Director on Return of
Organization Exempt From Income Tax.
KPHA performs utilization review procedures for Monroe County, therefore, having
responsibility for reviewing, approving or denying procedures and hospital stays
requested by physicians that belong to their own organization.
The Assistant Administrator of the Lower Keys Medical Center is also the Director of
Operations for the Keys Physician-Hospital Alliance. Independence in the
performance of their utilization review process for both prescription management and
the health plan is essential for the cost effectiveness of the plan.
Recommendation(s):
1. County Management should obtain clarification of the relationship between KPHA
• and Lower Keys Medical Center and whether or not there are any independence
issues that may negatively affect KPHA's ability to act on behalf of Monroe County
pursuant to the Employer-Provider Network and Utilization Review and Case
Management Agreement.
County Administrator's Response:
Management will attempt to clarify the relationship.
2. Documentation of Utilization Review Notes on Acordia's System
16
Finding:
As part of the audit and at the request of the Auditors, Acordia analyzed the utilization
review procedures of KPHA for six large case management patients with numerous
claims. In their review, Acordia stated "Overall the utilization review process appears
consistent with industry standards. The use of the criteria to validate admissions is
documented by the precert system. Appropriate clinical documentation was
accumulated to validate the ongoing hospitalizations. Evidence of discharge planning
was also appropriately documented. Case management activity appeared on the correct
cases."
The utilization review notes are not entered on Acordia's system but had to be researched,
copied and sent to Acordia by KPHA. Clinical documentation was noted as "sketchy"
by the Nurse Reviewer on one case. On another case she stated "One admission had
minimal documentation included, however, medical records had been attached which
validated the appropriateness of the stay. KPHA has the capability to enter the notes
directly into Acordia's system. Acordia's procedures require large physician bills and
hospital bills to be referred to the Cost Containment Unit for review and if these KPHA
clinical notes were in the system the Nurses and Claims Examiners would have all
pertinent information to make decisions on the claim.
Recommendation(s):
1. KPHA should enter clinical documentation directly into Acordia's claim system.
County Administrator's Response:
Management will require KPHA to enter their review notes directly into Acordia's
system.
3. Outside Audits For Large Hospitalizations
Finding:
According to Interisk Management, it is customary within the industry for large hospital
bills to be referred to outside vendors that carefully analyze the charges that could
include an in-hospital review of the patients' records to ensure all charges were for
services rendered. Acordia Management indicated it was their belief that referring a
claim for outside audit was normally not cost effective. The County may want to
verify this opinion by selecting a future claim and referring it to an outside vendor for a
detailed audit. One recent hospital stay was billed at $250,000 and was not reviewed
by KPHA Large Case Management. The savings on one large hospital bill could more
than pay for the cost of the service and often the fee is based on a percentage of the
savings. The procedure can be coordinated with KPHA and Acordia.
17 -
Recommendation(s):
1. Group Insurance Management should review the concept of audits of large hospital
_ bills.
County Administrator's Response:
This service is provided by Acordia. Their Cost Containment Staff reviews every
inpatient billing exceeding $10,000 in an out-of-network facility and every billing exceeding •
$40,000 in a network facility. The email describing their service is attached.
H. Employee Benefit Plan Document dated October 1, 1996
Finding:
The Monroe County Health Benefit Plan Document is dated October 1, 1996. Many
changes to the plan have been made since 1996. According to Acordia Management
they use e-mail documentation of many of the changes made to the plan. There-have
been three -formal written amendments to the Employee Benefits Plan Document.
These amendments are given to the employees and they are told to attach the
amendments to their plan document for future use. Claims Examiners and employees
refer to this document for information on the plan. Acordia Management further states
that ERISA requires the plan document be updated every 5 years, however, even
though Monroe County is an exempt governmental unit it would be beneficial to
Acordia when processing the claims if it was revised.
Recommendation(s):
1. Group Insurance Management should consider revising the Health Benefit Plan
Document.
County Administrator's Response:
Group Insurance Management is in the process of revising the Plan Document and it
will be reissued as soon as possible, but certainly within the first quarter of 2004.
Plan changes adopted by the Board of County Commissioners during April 2003
will be incorporated.
I. Payment Method Employed For Surgical Procedures
Finding:
Group Insurance stated that payment for surgical procedures should be calculated
according to Medicare's Multiple Surgery Guidelines and was under the assumption
that Acordia was using this method. Using Medicare's guidelines a second surgical
procedure performed during an operation is reduced to 50%. Acordia's method of
18 -
payment of surgical procedures is to reduce the second procedure to 50% if it is not
performed through the same incision as the primary procedure. One second surgical
procedure, CPT Code 36533 was paid at 100% or $1,200 as processed according to
Acordia's same incision policy. If it was processed according to Medicare's
Guidelines, the County would have paid $600 for this second procedure. Acordia
Management states there are very few operations where there is a second incision
required. Acordia Management further states it would be easier to process the claims
according to Medicare's Guidelines, however, if the network does not agree to using
Medicare's Guidelines the patient could be billed for any differences. •
Recommendation(s):
(1) Group Insurance Management should discuss the consequences of using
Medicare's Multiple Surgery Guidelines with KPHA.
2. Group Insurance Management should also consider including an acknowledgment
form to be signed by Acordia Management that states the change has been made and
the date it was implemented.
County Administrator's Response:
The proposal to use Medicare guidelines was suggested by KPHA management.
There will be further discussions of the consequences with them. Management
will incorporate an acknowledgment with all future changes.
J. Chiropractic and Massage Therapy Visits
Finding:
Chiropractic and Massage Therapy visits totaled $15,236 for the audit test period and
represents 5% of the total test amount. KPHA has recommended and the County has
implemented a limitation of chiropractic visits of 30 per year and massage therapy to
15 visits per year. Most physician bills reviewed for the audit test period were billed
with three to six procedure codes per visit. Internal audit was not able to review the
physician bills. Group Insurance Management might want to consider having KPHA
review the chiropractic and massage therapy billing to see if further oversight is
necessary, such as pre-certification or additional limits on the benefits.
Recommendation(s):
1. Group Insurance should coordinate the analysis of massage therapy and
chiropractic visits with KPHA.
County Administrator's Response:
In plan changes adopted April 17, 2003 by the Board of County Commissioners,
Massage Therapy was eliminated and Chiropractic Visits were limited to 15.
19
The limits discussed above by the auditor were implemented March 13, 2001.
The latest changes will satisfy the above recommendation.
•
20
.Y 03 14:10 FAA 31)4 353 8759 ACORDIA NATIONAL 2002 1'11
reb 12 03 04:31 p kph/33052960827 p,2
t'
11
Keys Physician -Hospital Alliance
February 07,2003
Ms.Beverly Burdett°
Vice President
Acordia National
602 Virginia Street, East
P.O. Box 3043
Charleston, WV 25331-3043
Dear Ms.Burdette:
• The Keys Physician-Hospital Alliance performs the,Utilization Review, Case Management and Quality
Assurance services for Monroe County. We also coordinate a network of providers. To that end, our
contract stipulates the reimbursement for services to be as follows:
KPHA Member 85% of billed charges with the cap of the 90'h percentile of the
Medicode Fee Schedule
In County Providers(IPN) 85% of billed'charges with the cap of the 90d'percentile of the
Medicode Fee Schedule
Out of County Providers(IPN) 70% of billed charges with the cap of the 90"' percentile of the
Medicode Fee Schedule
Dimension Providers Dimension Network Fee Schedule
Fisherman's Hospital 75%of billed charges -
Lower Keys Medical Center • 75%of billed charges
Our understanding is that if the physician's billed charge exceeds the 90''percentile of the Medicode Fee
Schedule that the 90*percentile will be utilized as the base reimbursement and the discount shall then be
applied. Please see examples listed below utilizing the KPHA and In County Network Provider
Reimbursement Schedule:
Example 1: Base Chaste does not exceed the 901s Percentile ofMedlcode
S100.00 Billed Charge
15.00 15%Discount •
•
$ 85.-00 Covered Amount(Minus pt.responsibility,co pays.and deductibles)
P.U.11 91117;Key Won.l'1tttit(7 131141-9107
(305)2'34-4i9')I Fax(3115)2944376
FE2-12-2003 16430 3052960027 92
P.02
u2/13/0003 14:16 FAX 304 353 8759 ACORDIA NATIONAL Ql 003
Feb 12 03 04:31p kpha 3052960027 p,3
Example 2: Base Charee exceeds 90thpercentile of the Medicode Fee Schedule
$100,00 Billed Charge
90.00 90111 Percentile of the Medicode Fee Schedule
13.50 15% Discount
$ 76.50 Covered Amount(Minus pt.responsibility,co pays and deductibles)
Please do not hesitate to contact me should you require additional information.
Sincerely., -
-
David a\ ,M.D,
Presiders
CC: James Roberts,County Administrator
Danny Kohlage,Clerk of Courts
DB/mlw
•
Ft1i-12-2003 16:30 3052960827 92
P.03
BOARD OF COUNTY COMMISSIONERS
Mayor Dixie M.Spehar,District 1
—.es11,4I Mayor Pro Tern Murray E.Nelson, District 5
C
U N TY ofM 0 N R 0 E _ 7 KEY WEST FLORIDA 33040 ' ••ice' . Charles"Sonny"McCoy,District 3
(305)N4-4641 � :� '.� ;.1•1 David P.Rice,District
Ts.ri natr _.
mat
. rqs-y, 444! sl..F •
Management Services
1100 Simonton Street .f
Key West,FL 33040
•
February 18,2003
Acordia National
602 Virginia Street,East •
P.0.Box 3043
Charleston,WV 25331-3043
Attention: Mr. Richard H.Legg
Dear Mr. Legg:
On February 7,2003,Dr. David Bannon,President of Keys Physician -Hospital Alliance,wrote to Ms.Beverly Burdette outlining the proper method
for processing daims. (Copy of this letter attached) This is to direct you to use this method on all daims. The Medicode listing to be used is the
update of November 2002.
Sincerely,
Sheila A.Barker
Division Director,Management Services
CC: James L.Roberts
Faxed: 304-353-8748
May 22 03 11 : 18a James L Roberts Co Rdmin 305-232-4544 p. 4
Fernandez-Maria
From: Beverly_Burdette@AcordiaNational,corn
Sent: Monday, May 05, 2003 11:19 AM
To: Fernandez-Maria@monroecounty-fl.com
Cc: Marcia_Nutter@AcordiaNational,com; Lora Denn
RichardLegg@AcordiaNational,com - y@AcordiaNational.com;
Subject: Re: Claim Audits
Maria, following is an overview of the services or internal cost containment unit-provides.
We do occasionally refer claims out for external audits, but this is done on a case by case
basis as recommended by our nurse reviewers.
We have an on-site cost containment unit (CCU) staffed by Registered Nurses to review
medical claims issues. The CCU staff reviews every inpatient billing exceeding $10,000 in
an out of network (Non-PPO) facility. In network claims (PPO) are reviewed when the
payment exceeds $40,000. This review includes appropriateness of length of stay,
diagnosis vs. procedures performed, appropriateness of medical equipment and drugs
based on clinical picture, and individual revenue line review for unusual or experimental
procedures. Also, they review all claims sent to them from the examiner staff to review
medical appropriateness for the following areas:
- All possible cosmetic procedures.
- All private duty or skilled nursing service.
- All durable medical equipment charges.
- All transplant preauthorization requests.
- All Rx drugs over $250.
- All surgery or anesthesia bills reduced due to R & C.
- All preauthorization requests for surgical procedures.
- All bills questioned by our unbundling software.
- All questionable provider bills.
- Assistance for claims appeals on medical issues.
- Excessive Lab Charges.
- Chiropractic charges if treatment plan exceeds six months.
Physician consultants are utilized when needed. External review firms are used for
specialty review. The client is notified of any specialty reviews prior to referral.
All large dollar hospital bills are reviewed by a registered nurse. As mentioned earlier,
inpatient claims in an out of network (Non-PPO) facility are reviewed when paid charges
exceed $10,000. All other claims including outpatient and all physician charges are also
reviewed when a paid claim exceeds $10,000. In-network (PPO) claims over $40,000 will be
reviewed retrospectively to insure Medically appropriate charges were considered with the
PPO discount. The length of stay, diagnosis and any operative procedures are reviewed in
accordance with the charges submitted. Evaluation of medical appropriateness based on
submitted information and evaluation of clinical status based on the bill. Any claim that is
an unusual dollar amount for services rendered or the miscellaneous expenses arc greater
than 20% of the total claim may be prescreened for external audit. The prescreening is
conducted by a. firm specializing in this type of review, and it is free. If the prescreening
firm recommends and audit, the client is contacted for permission prior to proceeding with
1 -
May 22 03 11 : 19a James L Roberts Co Rdmin 305-292-4544 p. 5
the audit. The fee is usually 33% of savings. If there are no savings, there is no fee,
excluding hospital or medical record fees. We use external firm for on-site hospital bill
audits. The entire medical record is usually reviewed onsite at the facility.
In addition, Monroe County participates in our Fee Negotiation Program. The reviewing
nurse will attempt to negotiate additional discounts for Non-PPO claims. A percentage of
the savings are retained to covered this service.
Bev Burdette
Vice President of Operations
Acordia National, Inc.
Phone (304) 353-8781
Fax (304) 353-8759
Email: Beverly_Burdett rc cordiaNational.corn
Richard Legg
• To: Beverly
05/02/03 04:39 PM Burdette/AcordiaNational@AcordiaNational,
Marcia
Nutter/AcordiaNational@AcordiaNational
cc:
• Subject: Claim Audits
Can you respond to this question
Richard H. Legg
Managing Senior Vice President & COO
Acordia National, Inc.
602 Virginia Street, East
Charleston, WV 25301
(304) 353 - 8779 Voice
(304) 353 - 8748 Fax
Email: Richard_Legg@acordianational.com -
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Forwarded by Richard Legg/AcordiaNational on 05/02/2003 04:37 PM
Fernand ez-Maria@monroeco
unty-fl.com To: Richard_Legg@AcordiaNational.corn
cc:
05/02/2003 02:03 PM Subject: Claim Audits
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