01/25/2013 AuditMONROE COUNTY COURTHOUSE
500 WHITEHEAD STREET, SUITE 101
KEY WEST, FLORIDA 33040
TEL. (305) 2944641
FAX (305) 295-3663
BRANCH OFFICE:
MARATHON SUB COURTHOUSE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289-6027
FAX (305) 289-1745
January 25, 2013
The Honorable Amy Heavilin
Clerk of the Circuit Court
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CLERK OF THE CIRCUIT COURT
MONROE COUNTY
www.clerk-of-the-court.com
Re: Review of prior Health Plan Agreements and run off claims
Dear Mrs. Heavilin:
BRANCH OFFICE:
PLANTATION KEY
GOVERNMENT CENTER
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852-7145
FAX (305) 852-7146
ROTH BUILDING
50 HIGH POINT ROAD
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852-7145
FAX (305) 853-7440
The Clerk's Internal Audit Department has completed a review of payments of claims and related invoices
under the agreements between Monroe County and Wells Fargo Third Party Administrator (TPA), Keys
Physician -Hospital Alliance (KPHA), MultiPlan, Inc. and Dimension Health Network. The County
Administrator requested a review of run-off claims when it was determined that the total paid was
approximately $1.2 million over the end of year estimate. Run-off claim data was analyzed for proper
processing, payment and timeliness of payment.
This review was conducted by Sandra L. Mathena, CPA, CIA, CFE, Director of Internal Audit with the
assistance of Michael D. Stanek, CIA, CCSA, Internal Auditor.
The accompanying audit review is provided for your information. Additional copies of the review will be
provided upon your request.
We would like to thank the Employee Services Division Director and her staff for their cooperation while
conducting the review.
Sincerely,
Michael D. Stanek, CIA, CCSA
Internal Auditor
cc: Board of County Commissioners (5)
Roman Gastesi, County Administrator
Teresa Aguiar, Division Director Employee Services
Bob Shillinger, County Attorney
Tom Ravenel, Clerk's Finance Director
REVIEW OF PRIOR HEALTH PLAN
AGREEMENTS AND RUN OFF CLAIMS
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January 25, 2013
Prepared by:
Internal Audit Department
Clerk of the Circuit Court
Amy Heavilin, Ad Interim
Clerk Monroe County, Florida
REVIEW OF PRIOR HEALTH PLAN
AGREEMENTS AND RUN OFF CLAIMS
OBJECTIVES AND SCOPE
The Clerk's Internal Audit Department has completed a review of payments of claims and related
invoices under the agreements between Monroe County and Wells Fargo Third Party Administrator
(TPA), Keys Physician -Hospital Alliance (KPHA), MultiPlan, Inc. and Dimension Health Network.
The County Administrator requested a review of run-off claims when it was determined that the
total paid was approximately $ 1.2 million over the end of year estimate. Run-off claim data was
analyzed for proper processing, payment and timeliness of payment.
METHODOLOGY
A. We interviewed the following personnel to obtain information about the Monroe County Group
Health Benefit Plan.
1. Teresa Aguiar, Division Director Employee Services Monroe County
2. Maria Fernandez -Gonzalez, Senior Administrator Employee Benefits Monroe County
3. Meggan Meggs, Senior Coordinator Employee Benefits Monroe County
4. Cynthia Hall, Assistant County Attorney
5. Suzanne Hutton, Monroe County Attorney
6. John E. Whitley, HealthSmart Benefit Solutions, Inc.
7. Eddie Reddick, MultiPlan
8. Terry Mullins, Wells Fargo Third Party Administrators
9. Lora Denny, Wells Fargo Third Party Administrators
10.The Clerk's Finance Department personnel
B. Internal Audit Department examined the following documents:
1. Florida Statutes related to the Group Health Benefit Plan
2. Monroe County Group Health Plan Document Effective January 1, 2010.
3. Monroe County local ordinances, resolutions, policies and procedures.
4. Health and dental claims registers.
5. Health Benefit invoices and related expenditures.
6. Monroe County checks for monthly payments.
7. Second Amendment to Administrative Service Agreement between Monroe County and
Wells Fargo Third Party Administrators dated May 20, 2009.
8. Third Amendment to Self -Insured Welfare Benefit Plan Administrative Service Agreement
dated October 19, 2011.
C. The Internal Audit Department reviewed the contract and amendments to ensure that the terms
and conditions were being complied with as documented within the Agreement.
D. Excel was utilized to analyze insurance claim data provided by the TPA for 2010 and 2011 for
proper processing, recording, billing and monitoring of the program.
E. Run-off claim data provided by HealthSmart was analyzed for proper processing, payment and
timeliness of payment.
BACKGROUND INFORMATION
Florida Statute 112.08 authorizes local government units to provide and pay out of its available
funds for all or part of the premium for officers and employees of a group plan. Each government
union may self -insure, subject to approval of the Office of Insurance Regulation, based on the
actuarial soundness of the plan.
The Board of County Commissioners has established a self -funded Employee Health Plan (the Plan)
originally effective on October 1, 1996 it was amended and restated effective January 1, 2007. In
self -funding, the County acts as its own "insurance company", paying its own claims and
administrative costs. In a self -funded plan, the employer assumes the claim risk. This claim liability
can be limited by a reinsurance company, who will reimburse claims that exceed a pre-set limit. Self -
funded plans are subject to federal laws, including the Health Insurance Portability and
Accountability Act (HIPAA).
Wells Fargo was the Third Party Administrator. The TPA is responsible for receiving, processing
and payment of claims. Health Smart bought Wells Fargo shortly after the contract ended. The
County pays the Third Party Administrator a monthly administrative fee for their services as well as
a fee for using their network. Blue Cross and Blue Shield of Florida, Inc. won the bid for the
County Health Plan. The new plan began on November 1, 2011. All claims incurred after
November 1, 2011 were adjudicated by Blue Cross and Blue Shield of Florida.
The current participants in the plan are employees of the:
Board of County Commissioners
Clerk of the Circuit Court
Land Authority
Property Appraiser
Sheriff's Office
Supervisor of Elections
Tax Collector
Internal Service funds are used to accumulate and allocate costs for the group health plan.
Preferred Provider Organizations (PPO)
Keys Physician -Hospital Alliance (KPHA) was the primary preferred provider organization for the
Monroe County Group Health Plan. A preferred provider organization is a managed care
organization of medical doctors, hospitals, and other health care providers who have contracted
with an insurer or third party administrator to provide health care at reduced rates to the members
of the plan. KPHA also provided precertification services. KPHA would not provide services to
2
Monroe County for the month of October 2011 causing the loss of discounts to the County and
their employees. The Blue Cross and Blue Shield contract did not begin until November 1, 2011.
Run-off Claims
The Third Amendment to the Self -Insured Welfare Benefit Plan Administrative Service Agreement
dated October 19, 2011 between Monroe County and Wells Fargo Third Party Administrators was
to specify the terms and conditions by which Wells Fargo will continue to handle claims during a
runout period following termination of the agreement. The administrative fee was ten percent of
total paid claims for the period starting November 1, 2011 through October 31, 2012, which was the
runout period. The Financial Review completed by Arthur J. Gallagher & Company dated August
29, 2012 stated "Claims experience under the new vendors continues to be favorable, although the
positive results are partly obscured by the fact that the actual runout from the Wells Fargo TPA
("WFTPA") will be $ 1.2 million more than the reserve the plan was holding as of September 30,
2011. See Exhibit— Financial Review"
Run-off Summary
Month
# of claims
Amount
Charged
Amount Paid
10% run-off fee
paid to the
TPA
November '11
1,053
1,523,165
527,875
52,072
December '11
2431
1,157,778
522,962
51,810
January '12
560
556,225
204,893
20,157
February '12
2,144
303,616
1,112463
11095
March '12
448
932,105
316,979
3080
April '12
153
427,788
210,676
20,40
May'12
273
737471
103,642
10,337
June '12
85
233,351
5308
5,309
July'12
172
407,975
43,628
4,339
August '12
50
110,571
1908
1,825
September '12
-2;254
0
Total
7,369
9,770,045
3,1131761
307,662
*** 'Amount Paid' includes payments to the 3rd party administrator for use of the
network.
3
AUDIT CONCLUSIONS
1. Wells Fargo (HealthStnart) processed run-off claims incorrectly using the 10% Dimension
discount rather than the 25% KPHA discount. This error resulted in an estimated $75,000 over
payment by the County.
2. An appeal approved in September 2011 was not processed until February 2012 costing the
County the 10% claims paid fee totaling $ 13,801.64.
3. Wells Fargo included vendor payments when invoicing the County for the 10% administrative
fee for processing run off claims. This resulted in the County being over billed $1,202.15.
4. The run-off claims paid claims billing for September was incorrect.
5. County paid approximately $115,000 to KPHA providers without BOCC approval.
6. Misclassified administrative fees charged by third party administrator without contract
amendment.
7. Group Insurance Management Should Provide Employee Education on Reporting
Possible Fraud or Abuse.
N
AUDIT FINDINGS
1. Wells Fargo (HealthSmart) processed Fishermen's Hospital run-off claims incorrectly
using the 10% Dimension discount rather than the 25% KPHA discount.
Finding:
During the examination of run—off claims, it was determined that Fishermens Hospital was paid
using the 10% Dimension discount rather than the 25% KPHA discount. All claims incurred before
September 30, 2011 should have been paid using the 25% discount. Only the claims paid between
October 1, 2011 and October 31, 2011 should have been paid using the Dimension discount of
10%. The estimate of the additional discount due is $67,855.78. The 10% of claims paid fee to
HealthSmart was also over paid approximately $6,785.58. The total overpayment is approximately
$75,000.
The third party administrator agrees with internal audit and has applied for a refund on one claim (#
433417) for $7,451.28.
According to the Administrative Service Agreement Section 27 (a) General Conditions "If an
auditor employed by the County or Clerk determines that monies paid to Acordia were spent for
purposes not authorized by this agreement, the Acordia National shall repay the monies together
with interest calculated pursuant to Section 55.03, FS, running from the date the monies were paid
to Acordia National."
We are waiting for HealthSmart to process additional refunds. Information requested from the
third party administrator has either not been provided or it was not provided on a timely basis.
Recommendation(s):
1. Group Insurance Management should pursue the refunds from the third party administrator.
County Administrator ResDonse(s):
1. Management will work with the County Attorney's office and send a letter to HealthSmart to
demand the refunds. We reserve all of our contractual rights in order to recoup the monies if
this becomes necessary.
0
2. An appeal approved in September 2011 was not processed until February 2012 costing the
County the 10% claims paid fee totaling $13,801.64.
Finding:
During the examination of run—off claims, it was determined that the appeal for claim number
414948 was approved in September 2011 but the adjustment claim (#431869) of $138,164.64 was
not processed until February 27, 2012. Since the claim was paid after November 1, 2011 the paid
claims fee of 10% was charged which was $ 13,801.46.
Internal Audit corresponded with John Whitley of HealthSmart about the slow payment of the
appeal and requested a refund of the paid claims fee. HealthSmart agreed and the County was told
not to pay the outstanding bills of $4,102.75 and a check would be issued for the difference of
$9,693.54.
The Clerk's Finance Department will have to complete a journal entry to record the transaction.
Recommendation(s):
1. Group Insurance Management should ensure that the refund from the third party administrator
is received.
County Administrator Response(s):
1. The refund was received by Group Insurance Management on December 5, 2012.
3. Wells Fargo included vendor payments when invoicing the County for the 10%
administrative fee for processing run off claims.
Finding:
The Third Amendment to Self -Insured Welfare Benefit Plan Administrative Service Agreement
provided for the payment of run -out claims for the period starting November 1, 2011 through
October 31, 2012 at a cost of 10% of paid claims. Wells Fargo overbilled the first three run-off
invoices by including 10% of vendor payments in the invoices. There were vendor payments to
Wells Fargo and Multiplan included in the claims report. The invoices which included the vendor
payments were as follows:
Wells Fargo Claims
Amount
$387,119.75
$140,755.04
$251,755.25
Vendor Payments
$7,133.40
$ 24.56
$4,863.51
Amount Overbilled
(10% of vendor payments)
$713.34
$ 2.45
486.36
$1,202.15
Internal Audit notified the Finance Department that 10% of vendor payments should not be paid
and the $1,202.15 was deducted from the amount paid. During the audit, HealthSmart (formerly
Wells Fargo) was notified by Employee Benefits of this error and future invoices were corrected.
Recommendation(s):
1. We recommend that all future network access fees be paid as a vendor payment and not be
included as part of the claims paid amount.
County Administrator Response(s):
1. Management understands the recommendation and will comply to the extent possible within the
parameters of our vendor agreements. In general, Network Access Fees are not part of the
contractual obligations with BCBSFL and are paid separately from claims as an inherent part of
the Administration Fee. However, there are limited circumstances that are identified in the
Administrative Services Agreement when an Access Fee is charged and is passed on to the
County as a claim liability at the time a claim is processed. The amount is contractually limited to
$2,000 per claim and represents contractual payments made to out of state BCBS Affiliates for
services performed.
7
4. The run-off claims paid claims billing for September was incorrect.
Finding:
HealthSmart incorrectly billed the County $1,824.75 for September 1, 2012 through September 15,
2012. This amount was the August paid claim total. The documentation provided to support the
claims was the August 2012 checks issued register. The incorrect billing was approved for payment
by the Sr. Benefits Administrator, Employee Services Division Director, and Deputy Administrator.
This billing was not paid. Internal Audit notified HealthSmart and a new bill should be issued.
Recommendation(s):
1. County Management should review all documentation to support an invoice before it is
authorized for payment.
2. County Management should ensure that the September 2012 billing is corrected.
County Administrator Response(s):
1. Management understands the recommendation and will appropriately review the support
documentation before it is authorized for payment.
2. The correct support documentation has been requested by both the Finance Department and
Management. As soon as it is received from HealthSmart it will be sent to Finance.
0
5. County paid approximately $115,000 to KPHA providers without BOCC approval.
Finding:
KPHA would not extend their contract one month; therefore the County lost the KPHA discount
of 25%. County Management directed the third party administrator to pay 100% of the discount
that was usually given by the KPHA network for the period October 1, 2011 through October 31,
2011. The letter from County Management states "Please be advised that for the effective dates
10/ 1 / 11-10/31 / 11, all claims received from a KPHA provider, who was solely in the KPHA
contracted network will be processed as follows: The discount that would have been taken prior to
10/ 1 / 11 will be deducted from the billed amount and the claim adjudicated as if the discount had
applied. The amount of the discount will be paid at 100% on a separate detail line and payable to
the provider. See Exhibit— Memo dated October 13, 2011 to third party ad-tninistrator.
Both Fishermens Hospital and Mariners Hospital were also in the Dimension network so the
Dimension discount was taken for the month of October and there was no additional cost to the
County. The 25% discount paid by the County to the KPHA providers was approximately
$ 104,413.44 and there was also the 10% additional claims paid fees of $ 10,441.34. The estimated
total additional cost was $114,854.78.
The payment of the 25% discount to the KPHA providers not in another network was not brought
to the Board of County Commissioners for approval.
Recommendation(s):
1. We recommend that the Board of County Commissioners formally approve any additional fees
charged by the contractors.
County Administrator Response(s):
1. The $ 115,000 was the cost of doing business in the transition period of changing providers. The
BOCC was aware of the transition and there was no mechanism in place to formally take to the
BOCC for approval. When KPHA declined to extend their contract, Management consulted
with the County Attorney's office. It was discussed and decided that because the direction to
third party administrator was not in the form of a contract (i.e., no signature required from Wells
Fargo) it did not require BOCC approval. Due to KPHA being unwilling to extend their
contract, Management had no choice other than to direct the third party administrator to
process claims (for the period of 10/ 1 / 11 — 10/31 /11) without the KPHA network discount
since we no longer had a contract with that provider. The direction to the third party
administrator enabled the County to pick up the discount (that would have been applied) at
100% without passing the loss of the discount to the employee. By terminating contracts with
the previous providers and contracting with Blue Cross Blue Shield of Florida, the County
Projected to save and has saved millions of dollars (See Exhibit A of the of the Review of prior
Health Plan Agreements and run off claims dated November 13, 2012).
Management understands the recommendation and will comply with it if any future incidents of
this type occur.
9
6. Misclassified administrative fees charged by third party administrator without contract
amendment.
Finding:
Monroe County had a contract with Multiplan, Inc. (MPI) a preferred provider organization
effective January 1, 2003 to allow access to MPI's network. MPI has created a network of healthcare
providers (MPI Providers), by entering into agreements with acute care and ancillary health care
providers (MPI Facilities), and physicians and other health care professionals (MPI Practitioners).
MPI's contract required Monroe County to pay 25% of the amount saved by using the preferred
providers in the network to Multiplan, Inc.
Private Healthcare Systems (PHCS) another PPO was purchased by Multiplan on October 18, 2006.
Wells Fargo began billing Monroe County for the PHCS network in March 2010. According to
Terry Mullins an employee of Wells Fargo, there was a conference call on June 28, 2010 with Rick
Legg, Maria Fernandez, Cindy Archer and Lora Denny which according to Wells Fargo gave Wells
Fargo permission to charge the County an additional administrative fee of 20% of network savings.
Monroe County did not sign an addendum or amendment to the contract with Wells Fargo. For
2010 Wells Fargo was paid $36,269.38 and for 2011 it was $99,823.81.
Wells Fargo was charging Monroe County 20% of savings to use the PHCS network. Wells Fargo
would not disclose how much they paid Multiplan to use the PHCS network. Eddie Reddick at the
Multiplan billing department stated that Wells Fargo paid 16% to use the PHCS network.
According to an e-mail dated November 2, 2011 from Ron Skipper the Senior Account Manager at
Multiplan "PHCS confirmed rate at 16% of savings. We'd prefer to get an addendum from you all
to add PHCS but that wasn't an option according to Maria when we met about it. We do have
contracts with all of our TPA clients for all of our products and require the client to tie their groups
to our agreement." See Exhibit— % rate. On November 3, 2011 Ron
Skipper sent another e-mail stating "Sorry but the rate is 25% of savings. My mistake on the last e-
mail. That's why I don't like to quote another client's rates." Exhibit D E-mail stating rate is
-
/a.
Wells Fargo completed an explanation of benefits (EOB) and a check payable to themselves and
included it as an insurance claim to be funded by Monroe County. The invoice charged Monroe
County 20% for use of the PHCS network. See Exhibit— EOB, Invoice
Allowing Wells Fargo to bill and write themselves a check from County funds circumvents internal
control. With proper monitoring a check payable to Wells Fargo written by Wells Fargo should
have been noticed and researched the first time it occurred. The check to Wells Fargo was not a
claim payment and should have been paid and charged as an administrative expense (vendor
payment) not as part of paid claims. The paid claims were over stated and the administrative
expenses for Wells Fargo were understated. An addendum to the contract should have been
completed as required by County policies and procedures.
Recommendation(s):
1. We recommend that the Board of County Commissioners formally approve any additional fees
charged by all contractors in compliance with policies and procedures.
10
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 Response(s):
1. When Group Insurance Management was notified that PHCS was purchased by Multiplan,
Group Insurance Management had discussions with Wells Fargo and it was understood that in
cases where a Provider was covered by both Multiplan and PHCS, the better discount would be
applied (i.e. Multiplan at 25% versus PHCS at 20%).
The check payable registers that were attached as support documentation were sent to Finance
each month and showed the fees being paid to Wells Fargo when the PHCS and Multiplan
network was used. (See Exhibit A and B attached).
Management understands the recommendation and will comply with it if any future incidents of
this type occur.
2. Group Insurance Management will work with the Consultant to establish set guidelines to
perform audits and inquiries periodically.
Auditor Comments:
It is the business owner's responsibility; in this case Employee Services, to over -see the County's
Health Plan. Finance's responsibility is to enter the financial information submitted to them from
the various business owners. The County Administrator's Exhibit A reinforces this point.
Employee Services has signed -off, in multiple locations that "I hereby certify that I have reviewed
the attached register. The payments being issued are for the employees and/or dependents who are
enrolled in the Monroe County Insurance program at the time service rendered. Totals are also
correct."
Note that the County Administrator's Exhibit A and B have been highlighted for this report. This
information had not been highlighted when sent to the Finance department.
11
7. Group Insurance Management Should Provide Employee Education on Reporting
Possible Fraud or Abuse
Finding:
Offers to waive coinsurance and copayment amounts are considered fraud according to Florida
Statutes 817.234 — False and fraudulent insurance claims. Accepting an employee's insurance as
payment in full and disregarding the copayment or deductible results in overbilling the Monroe
County through the TPA. It is considered unethical by the medical profession.
Physicians, dentists, and outpatient facilities are not reducing their fee when they do not collect
patient payments. Instead these providers are charging inflated fees to the TPA to make up for the
money they lose from waiving the coinsurance/copayment amounts.
Employees who knowingly agree to the scheme are participating in this deception. However, we
have no evidence of providers or facilities trying to attract more business by participating in this
practice.
No matter how irresistible the offer of free services seems, the care you receive isn't really free. As a
result, it increases costs and the health plan becomes more expensive. BlueCross BlueShield of
Florida has an Insurance Fraud and Abuse Report on their website. See Exhibit Insurance
-
Fraud and Abuse . Employees should also be advised that a self insured plan means that
Monroe County pays for each claim and any fraud could increase the contributions made by
employees and retirees.
Recommendation(s):
1. Group Insurance Management should establish policies and procedures to educate employees on
this issue and provide procedures for the employees to report the issue to the Group Insurance
Department or directly to BlueCross BlueShield of Florida, Inc.
County Administrator Response(s):
1. Group Insurance Management will comply with the recommendation and work with the
Consultant and develop a Notice to employees regarding False or Fraudulent Insurance Claims.
The notice will be provided with all New Hire Packets, be posted on the Benefits website and
will be distributed during the annual open enrollment.
12
V. EXHIBITS
EXHIBIT A
Financial Review August 29, 2012
MONROE COUNTY
BOARD OF COUNTY COMMISSIONERS
FINANCIAL REVIEW
AUGUST 29, 2012
Presented by:
Rick Capizzi
Area Assistant Vice President
Glen Volk
Area Vice President, Actuarial Services
Arthur J. Gallagher & Company
Gallagher Benefit Services
2255 Glades Road, Suite 400E
Boca Raton, FL 33431
Monroe County Board of County Commissioners
Health plan Financial Results through .July 2012 --- Highlights
Claim experience under the new vendors continues to be favorable, although the positive
results are partly obscured by the fact that the actual runout from the Wells Fargo TPA
("WFTPA") program will be $1.2 million more than the reserve the plan was holding as of
September 30, 2011. We have also seen some large claim activity that has affected the
current year results, although claim activity in July was in line with expectations. We
estimate that mature medical claims have fallen from $1.1 million per montb under a prior
program to approximately $725,000 per month under the BCBSFL progra;'Jestimated
Pharmacy
claims also continue to run lower than last year's level and that works out annual
savings of over $400,000 in prescription drug costs. We remain confident that the County
will see savings in excess of the levels that we had initially suggested. (Page 1)
As expected, we continue to see a much faster claim payment pattern under the BCBSFL
program than we saw under the WFTPA program. The plan historically held claims reserves
of approximately $2 million under the WFTPA. program, while we expect the average reserve
under the BCBSFL program will be approximately $900,000 to $950,000 based on the early
claim results. This will result in a drop of over $1 million in the claim reserve (IBNR). dote
that the actual runout under the WFTPA program has already reached $3 million, so the
reserve held at September 30, 2011 was understated by over $1 million. (Page 2)
Because of the higher than expected runout from the WFTPA program we project a loss of
$400,000 for the plan for the current fiscal year. This is still a significant improvement over
the prior year. (Page 3).
We still project that the County will not have to increase the health plan budget or funding
rates for FY 2013. The 2013 year will be helped by the absence of both the estimated $1.2
million loss on runout claims and the $300,000 expense associated with the WFTPA runout
processing. FY 2013 will be the first year in which the County realizes all of the savings
associated with the new vendors without having to pay any of the costs associated with the
transition away from the prior vendors. With the July experience, we project that the plan
will realize a small gain of $200,000 for the 2012/13 plan year if the current budgeted
revenue is continued into 2013. (Page 4)
e We project that the plan surplus will fall from $12.2 million to $1 I ,9 million this year and
then increase to $12.1 million by the end of the 2012/13 plan year at the current level of
funding. 'Phis is a very comfortable surplus amount and easily satisfies the Office of
Insurance Regulation (01R) safe harbor surplus threshold. (Page 5)
O In the first 9 months under the BCBSFL program, there have been 15 claimants who have
exceeded $50,000 in medical claims paid. The highest claim amount is over $320,000, with
a second claimant at just over $240,000, In total the claimants represent over $1.5 million in
claims, or 15.5% of the total claims paid so far this year. These totals are up only slightly
from the June report. This is somewhat deceptive in that the WFTPA data is not included
and that would almost certainly cause the number and amount of large claimants to be higher.
This measure will become more credible as the BCBSFL program becomes more mature and
the WFTPA program continues to wind down. (Page 6)
Monroe County Board of County Commissioners
Financial Review
August 29, 2012
TABLE OF CONTENTS
Total Net Paid Prescription Drug and Medical Claim Summary 1
October 1,2009 through July31,2012
IBNR Analysis Based on Claims Paid Through July 2012 2
Status Report as of July 31, 2012 3
Renewal Projections -- October 1,2412 through September 30, 201.1 4
Assuming Current Enrollment
Projected Fund balance and Reserve Adequacy — As of July31,2012 5
Large Claim Summary as of July 31, 2012 6
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Total Net Paid Prescription Urugj and Medical Claim Summary
October .l, 2009 through My 31, 2012
Claims Paid
WFTPA
BCBSFL
Month
Enrollees
Rx
Medical
Medical
Total
Oct-09 1,.S88
$168,838
$1,192,721
$1,361,559
Nov-09 11582
172,722
1,066,022
1,238,744
Dec-09 13,587
198,020
117202095
1,918,115
Jan-10 1,594
176,372
697,116
873,487
Feb-10 1, 599
177,655
986,646
1,164,301
Mar-10 1,594
211,999
11124,366
103369365
Apr-10 11600
201,399
785,118
986,517
May-10 19600
18 33 308
914,499
19097,806
Jun-10 11598
190,794
110430445
1,234,239
Jul-10 13600
195.522
816,370
19011,892
Aug-10 13596
197.355
879,241
11076,596
Se -10 1,589
2149l74
7939675
190079,849
Oct-10 1,598
2011061
761,233
9621294
Nov-10 1,598
204,259
11149,555
1,3139813
Dec-10 11597
2141174
1,29OA4:32
1,5049605
Jan-11
11600
?39,704
1,124,618
12364,322
Feb- 11
1,597
183,576
722,663
906,239
Mar- 11
1,595
208,054
924,985
19133,039
Apr-11
1$92
209,798
9721$425
1,182,223
May-11
19591
21 1,681
112.569565
1,4680246
Jun•11
15587
2061102.
1,2051,139
1,411,241
Jul-11
11588
194,953
110031869
1,198,822
Aug-11
11595
226,269
717,596
943,865
Sep-1 1
11584
202 521
1,1529396
19354,917
Oct-11
11588
161,630
783,236
944,866
Nov- 11
1,591
177%409
5271875
$2.601262
965,546
Dec-11
1,593
1871183
522,962
456,951
19167,097
Jan-12
1.599
197,650
104,892
440,308
842,850
Feb-12
l .597
211,115
I , 112,463
418,426
19,742,004
Mar-12
11615
2099259
316,979
9641,109
194909347
Apr-12
1,622
1 ill :404
210,676
943,373
193450453
May-12
11607
210,016
103,642
802,083
111159741
Jun-12
19612
200,431
53,088
5859872
839,391
Jul-12
1,608
190,616
761,046
951,662
2009/10
19,127
$292882159
$12,0191314
$0
$149307,472
2010/11
19,122
$2,5020150
$129241,475
$0
$14,743,626
2011/12 YTD
16,032
$1,936,713
$3,8359813
$5,632,430
$1194049956
Last 12 Mos
199211 1
$2,365,502
$5,7059806
$59632,430
$13,703,738
PEPM
2009/10
$119.63
$628.40
$0.00
$748.02
2010/11
$130.85
$640.18
$0.00
$771.03
2011/12 YTD
$120.80
$239.26
$351.32
$711.39
Last 12 Mos
$123.13
$297.01
$293.19
$713.33
MCBCC Report 072012 1 8/28/2012
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
IBNR Analysis Based on Claims Paid Through July 2012
Medical - BCBSFL Only
Rolling Twelve
Cumulative
Paid to mate
Outstanding
Incurred
Months
Incurred
Exposure
Claims by
Completion
Claim
Outstanding
Claims Per
Incurred
Clahns Per
Incurral Month
Unit
Incurral Date
Factor
Incurred Claims
Reserve
Claim Reserve
Unit
Claims Per Unit
Unit
6 Month
(Before
(Margin
LIVES
Averaging
Margin)
Applied)
PEPM
PEPM
PEPM
Nov-11
11591
$582149
0.9965
$584,194
$2,045
$2,147
$367.19
$367.19
$367.19
Dec-11
1,593
$534:845
0.9946
$537,737
$21,893
$39037
$337.56
$352.37
$352.37
Jan-12
10599
$753,114
0.9938
$757,833
$4,719
$4,955
$473.94
$393.01
$393.01
Feb-12
11,597
$733,940
0.9921
$739,800
$59860
$6,153
$463.24
$410.59
$410.59
Mar-12
1,615
$8390200
0.9781
$858,007
$18,807
$19,747
$531.27
$434.97
$434.97
Apr-12
1,622
$586.882
0.9392
$6241,871
$37,989
$390888
$385.25
$426.58
$426.58
May-12
11,607
$6120288
0.9182
$666,833
$54,545
$57,272
$414.96
$424.92
$424.92
Jun-12
11,612
$6419900
0.7450
$861,634
$219,734
$2309721
$534.51
$438.68
$438.68
Jul-12
19,608 1
$335 642
0.4468
$751 251
$415 609
$436 389
$467.20
$441.86
$441.86
2011I12
14,444
SS 619 959
88.06%
S6 382159
S762 00
$$00 t0 +-$441.86
Average Monthly Claims $ 750,399
Recommended Reserve $ 800,310
Reserve in Months of Claims 1.07
Recommended Pharmacy Reserve
YTD Avg Monthly Paid Claims $ 193,671
Estimated Lag in Months 0.50
Estimated Reserve 1 $ 96,835
Medical + Pharmacy Reserve
Total Recommended Reserve $ 8970145
Total Average Claims $ 944,071
Total Reserve in Months 1 0.95
MCECC Report 072012 2 8/28/2012
MONROE COUNTY BOARD of COUNTY COMMISSIONERS
Status Report as of July 31, 2012
Actual YTD
Projected
Per GBS
Year End
1.
Total Gross Paid Claims (1)
a. WFTPA
$
31835,813
$
31935,813
b. BCBSFL
$
51632,430
$
71104,456
c. Envision
..,....__....
-1,936,713
$ , 2,340,456
Total Paid Claims
$
11,404,956
$
13,380,726
ll.
Fixed Costs (2)
a. WFTPA
$
300,983
$
310,983
b. BCBSFL
6573202
8030530
c. Envision
60,120
721180
d. Internal Expenses
181,248
2171498
e. Other M138, Life AD&D
_.._
264.137
_
316,964
Total Fixed Costs
$
11463,690
$
11721,155
III.
Total Paid Plan Costs
$
12,868,646
$
15,101,880
IV.
Funding
a. Contributions (4)
$
11,265,477
13,525,318
b. Interest (3)
$
83,333
$
100,000
c. Other
Total Funding
$
11,3489810
$
13,6259318
V.
Cash Surplus/(Deficit)$
11519,836)
$
11476,562
V1.
Change in Claim Reserve
a. Starting Reserve
$
2,024,412
$
21024,412
b. Estimated Closing Reserve
$
897,145
$
911,510
c. Change in Reserve
$
11127,267
$
1,1129902
V11.
Incurred Surplus/(Deficit)
$
392,669
$
363,661
V111.
Incurred % Surplus/(Deficit)
-3.5%
-2.7%
(1) Based on paid claims through July 31, 2012.
(2) Based on fixed rates and reported and/or projected enrollment and actual WFTPA
(3) Based on September 2011 Financial Statements.
(4) Based on enrollees multiplied by current funding rates.
MC BCC Report 072012 3 8/28/2012
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Renewal Projections
O& ober_1 2012 through September 30. 2013 Assuming Current Enrollment
Projected
Assumed
Projected
2011/12
% Change
2012/13
I. Total Net Incurred Claims 1
$
12,2679824
9.6%
$
11,943,223
II. Fixed Costs (2)
a. WFTPA
$
3101983
-100.0%
-
b. BCBSFL
8031530
3.0%
9041211
c. Envision
729180
0.0%
72,360
c. Internal Expenses
217,498
4.0%
226,198
d. Other GBS Life AMID)
31fi,964
0.0%
316,964
Total Fixed Costs
11721,155
0.0%
1,519,732
III. Total Plan Costs 2
$
13,9880979
$
13,462, 956
IV. Revenue at Current Level
13,625,318
0.0%
$
13,6599047
V. Surplus/(Deficit) With No Change in Funding
$
363,661
$
196,091
Vl. Increase Required to Break Even in 2012113
NIA
0.0%
$
139659,047
Notes: (1) 2011/12 Net Claims $ 13,380,726
1,112, 902
$ 12, 267, 824
(2) 2011/12 Total Plan Costs from Prior Page $ 15,101,880
- �.�.(1 1 112,902)
$ 13, 988, 979
(3) Projected 2012/13 Funding $ 13,659,047
$ 100,000
$ 13,559,047
x 1.0000
$ 13,559,047
$ 100,000
$ 131659,047
Projected Paid Claims
Reserve Change
Total Paid Plan Costs
Reserve Change
Annualized Funding at 2012 Rates
Less Interest and Other Income
Annual Contributions
Required 1/1/13 Increase
Resulting 2013 Contributions
Plus Interest and Other Income
Total Projected 2013 Revenue
MC BCC Report 07�2012 4 8/28/2012
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IMONROE COUNTY BOARD OF COUNTY COMMISSIONERS
BCBSFL Large Claim Summary as of July 31, 2012
Total YTD Claims (Medical & Pharmacy) $ 11,404,956
Large Claims as 16.5%
% of Total
* Includes claims paid by BCBSFL only
MCBCC Report 07.2012 6 8/28/2012
Monroe County Board Of COURtY Commissioners
Summary of Annual Health Plan Builts
And
2011/2012 Network Savings Estlimate
August 29, 2012
tno
Presented 13y-
Rick Cap izzi,
Area Assist(ant Vice president
GIcn Volk
Area Vice Presidciit, AdUarial Services
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EXHIBIT B
Memo dated October 13, 2011 to third party
administrator
OUNW o MON ROE
KEY WEST FLORIDA 3304
t3051294.4641
CA" of the Empkyoe Services DWon Director
'Me Htstaric Guo Cyr fw"
1100 SfMantar Sbut, Sulu 268
Kerr West. Ft U040
(305) 292-4458 — Phone
(305) 2924564 - Fie
October 13, 2011
Wells Fargo Third Party Administrators, Inc.
602 Virginia St. E.
Charleston, WV 25301
Attn: Debbie Duespohl, CEBS
Assistant vice President, Operations Manager
Mayor Headw Carruthers, Dlstrkt 3
Mayor Pro Tem David � RIces DisWct 4
iam ftington, DOict I
George Heugent, Dist rd 2
Sylvia I Murphy, Distract 5
Please be advised that for the effective dates of service 10/1/11.10/31/il, all claims received from
a KPHA provider, who was solely in the KPHA contracted network with Monroe County prior to
10/1/11, will be processed as follows:
The discount that would have been taken prior to 10/1/11 will be deducted from the billed amount
and the claim adjudicated as If the discount had applied. The amount of the discount will be paid at
100% on a separate detail line and payable to the provider. Providers In Dimension and/or
Multiplan will be processed according to our current network agreements. Claims received from
providers who were in KPHA are currently in either Dimension or Multiplan will be processed
according to those current contracted network agreements with Monroe County,
If you have any questions, please contact me Immediately.
2 SinceS i nce r ly,
Lernandez•Gonzalez,
Sr. Benefits Administrator
Final concurrence,
• Roman Ga stesY
County Administrator
Zres
ui ,
Division Director Employee Services
EXHIBIT C
E-mail. confirming 16% rate
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EXHIBIT E
EOB, invoice and check
Wells Fargo Third Party Administrators, Inc. EXPLANATION OF BENEFITS
***THIS IS NOT A BILL***
P
'ayment Calculation:
GRAND TOTALS
PAY PROVIDER AMOUNT DUE --->
10322.;
10322.31
T.':YEAR
20- t J 1 01200000130
SEE BACK FOR
MORE INFORMATION
EMPLOYER. MONROE CNTY ORD OF COMMISSION
PROVIDER PAID
WELLS FARGO 3RD PARTY AQMIN 10,322.38
602 VIRGINIA ST E
CHARLESTON WV 25301-2154
MONROE COUNTY
ATTN : MAR I A FERNANDE Z
1100 SIMONTON ST -�
SUITE 2 272
KEY WEST FL 33046
NON NEGOTIABLE
IF YOU HAVE ANY QUESTIONS CONCERNING THIS BENEFIT DETERMINATION, PLEASE CONTACT WELLS FARGO THIRD PARTY
ADMINISTRATORS, INC. AT 800.624.8605 BETWEEN 7:00 AM AND 7:00 PM EST OR WRITE TO PO BOX 3262, CHARLESTON, WV
25332.
For Web access go to tpa.wellsfarago.com and click 'For the Client, Employee, Provider'.
F�FMARK CQQF • NOT COVERED:
EXPLANATION;�OF�� -
SV PPO SAVINGS FEES
Image $120111012GO01 71003 Page 02 Of 2
060- INVOICS
242130 Wells Fargo.Third Party Administrators, Inc...
DESCRIPTION AMOUNT
PRCS W OF SAVINGS FOR THE MONTH (S) OF:
SEPTEMBER, 2011 20% X $51o611-91 $10,3224.38
Should you have any questions, please contact: ji. OCI T 1 2 2 0 11
WELLS FARGO TPA
TERRY MULLINS EXTENSION 8807
(800) 332 -4 73 2.
SALES TAX
Total Billed: $101322-38
Please make chock payable to:
WELLS FARGO TPA
DO BOX 535100
ATLANTA GA 303535100
MONROE COUNTY GROUP INSURANCE
ATTNI BETTY CAR ER
*** CUSTOMER COPY ***
PAYMENT DUE UPON RECEIPT
DATE
INVOICE'E'.4
ACCOTR1T
10/01/11
242130
5830-PHCS
BRIER
'CUSTOMER
AMOUN111 DUE1
99 4603
$101322.3�1
,1;C;V-06-20'2 03-02 PM CAPITAL INVESTM �j T q
NAPLES 2392634543 2 /2
It= Detail Page I of I
Item Detail�..1����r��. BANK
Check 1 of I Status: Paid
DNA"
Monroe County 0 ATU f0/ 13/ MM f
Ornup TIO BANK 0 Ow KEYS
XEY 'SST, S. ;iT
EXAM' 0*404(322 DOLLARS 1.08 CEWS
VQ11DL AMR �*'DAYS
JeN
LLA
PAY TO FA90 3RD PARTY -AMIN
OMM OF
UALESTOR WV
Now
'http-.//192.168.150.9.)�/'Ichcck/Check-Detail.,-tsp 11/6/2012
EXHIBIT F
Insurance fraud and abuse report
BlueCross BftieShield
of Florida
An In dopond4w Ucomwo cal ft
Blue C ross and Bkm Shoed ASS00WOn
Insurance Frain. and Abuse Report
To report suspected insurance fraud or abuse, please complete the information requested below.
Items marked with an asterisk are reqUlred for filing, Once the form is complete, please send to -
Blue Cross and Blue Shield of Florida, Inc.
Special Investigation Unit
PO Box 44193
Jacksonville, FL 32,231-4193
Please submit separate entities for each suspect.
SUSPECT OF COMM117ING THE FRAUD/ABUSE
"Narne Ondividual. or Company)
"Address
*City *State *Zip
Telephone Number Profession Professional License # (if known)
LIST VICTIMS) OTHER THAN YOURSELF
Name
Andress
City state Zip
Daytime Telephone Number BCBSF Contract # (if applicable)
COMPLAINANT (Yourself)
*Your Name
'Address
*City State Z_;0
*Daytime Telephone Number E-mail Address
Have you attempted to contact the person(s) suspected of committing the fraud/abuse Concerning your complaint? Yes No
If Yes, when?
63103-0804 Page I of 3
BlueCross BlueShield
of Florida
An kodapvWeal Lkensee of ft
Bkoe Cmu " Bkw Sh*dd AnWation
WITNESSES (Please give full name, address and phone number)
Please list all individuals who may have knowledge concerning the activity that may be fraudulent or abusive. It you have additional
witnesses, please list in the comments section of this report,
Witness Name
Address
City
State
Zip
Home Telephone Number
Work Telephone Number
Witness Name
Address
City
State
Zip
Home Telephone Number
Work Telephone Number
Witness Name
Address
city
Siam
Zip
Home Telephone Number
Work Telephone Number
Wliness Name
Address
City
State
zip
Home Telephone Number
Work Telephone Number
Witness Name
Address
city
Slate
ZIP
Home Telephone Number
Work Telephone Number
63103-0804 Page 2 of 3
BlueCross BlueShield
errof Florida
An hdeporldent LwAnsec% of the
Blue Croj4 " 9juq3 Shield Aswckalkon
DESCRIPTION OF FRAUD OR ABUSE
Please provide as much information as possible in the space below concerning your complaint. Be sure to include all details such as
date it took place. etc.
63103-0804
Page 3 of 3
County Administrator Response
County of Monroe
The Fl1* Keys
The Historic Gato Cigar Factory
1100 Simonton Street
Key West, FL 33040
December 18, 2 0 12.0
Michael D. Stanek, CIA, CCSA
Monroe County Clerk of Courts
Internal Audit Department
RE- Health Plan Audit Response
Dear Mr. Stanek:
BOARD OF COUNTY COMMISSIONERS
Mayor George Neugent, District 2
Mayor Pro Tem. I leather Carruthers. District 3
Danny L. Kolhage. District I
David Rice. District 4
Sylvia J. Murphy. District 5
W
In response to the draft of the prior health plan agreements and run off claims, I offer the following responses to the
Findings and recommendations-
1. Wells Fargo (HealthSmart) processed Fishermen's Hospital run-off claims incorrectly using the 10%
Dimension discount rather than the 25% KPHA discount.
Recommendation(s):
1. Group Insurance Management should pursue the refunds from the third party administrator.
County Administrator Response(Eh.
1. Management will work with the County Attorney' s office and send a letter to health mart to demand the
refunds. We reserve all of our contractual rights in order to recoup the monies if this becomes necessary.
I
An appeal approved in September'201 I was not processed until February 2012 costing the County the 10%
claims paid fee totaling S13,801.64.
Recommendation(s):
1. GrOLIP Insurance Management should ensure that the refund from the third party administrator is received.
I
Countv Administrator Respons
1. The refund was received by Group Insurance Management on December 5, 2012.
3. Wells Fargo included vendor payments when invoicing the County for the 10% administrative fee for
processing run off claims.
Recommendation(
1. We recommend that all future network access fees be paid as a vendor payment and not be inciuded as part of the
claims paid amount.
Countv Administrator Res ponse(s):
1. Management understands the recommendation and will comply to the extent possible within the
parameters of our vendor agreements. In general, Network Access Fees are not part of the contractual
obligations with IBSFL and are paid separately from claims as an inherent part of the Administration
Fee. However, there are limited circumstances that are identified in the Administrative Services
Agreement when an Access Fee is charged and is passed on to the County as a claim liability at the time a
Z3 in
claim is processed. The amount is contractually limited to $2,000 per claim and represents contractual
payments made to out of state BC BS Affiliates for services performed.
December 18, 2OL2.
Health Plan Audit Response
Page 2 of 3
4. The run-off claims paid claims billing for September was incorrect.
Recommendation(s):
1- County Management ShOUld review all documentation to support an invoice before it is authorized for payment.
I",
2. Count r Management s h o Li I d ensure that the Se pte in ber 2 012 billing is corrected.
County Administrator Respons
I Management understands the recommendation and will appropriately review the support documentation
before it is authorized for payment.
2. The correct support documentation has been requested by both the Finance Department and Management.
As soon as it is received from HealthSmart it will be sent to Finance.
5. County paid approximately SI 15,000 to KPHA providers without BOCC approval.
Recommendation(s):
I We recommend that the Board of County Commissioners formally approve any additional fees charged by the
contractors.
County Administrator Resppp
1. The $115,000 was the cost of doing business in the transition period of changing providers. The BOCC was
aware of the transition and there was no mechanism in place to formally take to the BOCC for approval.
When KPHA declined to extend their contract, Management consulted with the County Attorney"s office.
It was discussed and decided that because the direction to third party administrator was not in the form of
a contract (i.e., no signature required from Wells Fargo) it did not require BOCC approval. Due to :PHA
being unwilling to extend their contract, Management had no choice other than to direct the third party
administrator to process claims (for the period of 10/1/I I — 10131 A 1) without the KPHA network discount
since we no longer had a contract with that provider. The direction to the third party administrator
enabled the County to pick up the discount (that would have been applied) at 100% without passing the loss
of the discount to the employee. By terminating contracts with the previous providers and contracting with
Blue Cross Blue Shield of Florida, the County projected to save and has saved millions of dollars (See
Exhibit A of the of the Review of prior Health Plan Agreements and run off claims dated November 13,
2012).
Management understands the recommendation and will comply with it if any future incidents of this type
occur.
6. NI Ise I a- ss I fied administrative fees charged by third party administrator without contract amendment.
Recommen dation(�h':
I We recommend that the Board of County Commissioners fomially approve any additional fees charged by all
contractors in compliance with policies and procedures.
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 tMon
1. When Group Insurance Management was notified that PHCS was purchased by Multiplan, Group
Insurance Management had discussions with Wells Fargo and it was understood that in cases where a
Provider was covered by both Multiplan and PHCS, the better discount would be applied (i.e. Multiplan at
25% versus PHCS at 20%).
The check payable registers that were attached as support documentation were sent to Finance each nionth
and showed the fees being paid to Well Fargo when the PHCS and Multiplan network was used. (See
Exhibit A and B attached).
Management understands the recommendation and will comply with it if any future incidents of this type
occur.
2. Group Insurance Management will work with the Consultant to establish set guidelines to perform audits
and inquiries periodically.
December 18,2011
Health Plan Audit Response
Page 3 of 3
7. Group Insurance Management Should Provide Employee Education on Reporting Possible Fraud or Abuse.
Recommendation(§h'.
I Group Insurance Jana (lernent should establish policies and procedures to educate employees on this issue cand
provide procedures for the employees to report the issue to the Group Insurance Department or directly to
Blue 'Toss BlueShield of Florida., Inc.
County Administrator Reponse(s):
1, Group Insurance Management will comply with the recommendation and work with the Consultant and
develop a Notice to employees regarding False or Fraudulent Insurance Claims. The notice will be
provided with all New Hire Packets, be posted on the Benefits website and will be distributed during the
annual open enrollment.
Sincer
Roman Gastesi,
County Administrator
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