Purpose

To determine whether United’s charges were accurate and related to the administration of the Empire Plan.  The audit covers the three fiscal years ended December 31, 2010. 

Background

The New York State Department of Civil Service (Civil Service) is responsible for administering the New York State Health Insurance Program (NYSHIP). NYSHIP provides health insurance coverage to more than 1.2 million active and retired State employees, participating local government employees and school district employees and their dependents. NYSHIP includes several health plan options, of which the Empire Plan is the largest.  Civil Service contracts with United HealthCare (United) to process and pay medical and surgical claims for services provided to Empire Plan members.  During the period January 1, 2008 to December 31, 2010, the State paid United more than $50 million for direct costs related to employee compensation and benefits under the Empire Plan’s medical/surgical contract.  The State’s contract with United requires all administrative costs charged to the State to be related to United’s administration of the Empire Plan’s medical/surgical program. In addition, a State contractor must maintain complete and accurate records to support its claims for six years.

Key Findings

• For portions of our period, United did not maintain certain source and summary data to support the charges for time worked by claims and call center staff assigned to the Empire Plan.  
• United did not have a uniform method to track and account for the time worked by claims center staff. 

Key Recommendations

• For no less than six years, maintain the source and summary data to support charges for the compensation and benefits of claims and call center employees who administer the Empire Plan’s medical/surgical program. 
• Develop a standardized process to track and account for time worked by claims center staff.

Other Related Audit/Report of Interest

New York State Health Insurance Program - United HealthCare: Certain Claim Payments for Evaluation and Management Services (2010-S-67)