Claims audits identify errors and penalties for UMR and VIA; board accepts findings and penalties

Independent auditors presented quarterly claim audits for vendors that administer PEP plans and recommended remedial steps and penalties for missed performance guarantees.

CTI presented a UMR claim audit covering 04/01/2025–06/30/2025. Auditors reported approximately $73 million in medical and dental payments across ~245,000 claims during the quarter, and a stratified random sample and operational review. The contractors met the 14‑day turnaround guarantee but fell short of some financial‑accuracy metrics and the 99% within‑30‑day guarantee. "This results in a penalty of 3.5% of the administrative fees for the quarter or $49,149.60," Joni Amato of CTI said. UMR representatives said they are reviewing the identified errors, running additional reporting and taking corrective steps for manual pricing instances and contract‑timing issues.

CTI also noted identified overpayments and adjustments (auditors flagged roughly $1,000,000 of adjustments identified for potential recovery), and discussed appeals timing; CTI recommended root‑cause analyses and staff training on provider discounts and plan exclusions.

A second audit covered VIA Benefits’ HRA administration (07/01/2024–06/30/2025). CTI reported approximately $19.4M paid across ~180,000 transactions, five random sample errors (three financial — including duplicate payments — and two procedural), and two missed self‑reported customer‑service metrics, yielding a $10,000 penalty for the 2025 plan year. Willis Towers Watson and VIA representatives explained open‑enrollment call volumes and staffing challenges during Medicare season and said steps have been taken to improve staffing models and automated call systems.

Board action: The board moved to accept both audit reports and to collect the identified penalties and directed vendors to provide follow‑up reporting describing root‑cause analyses and recovery/recoupment status. The motions carried.

Next steps: UMR and VIA will provide follow‑up reporting on additional analysis, overpayment recovery and operational fixes; the board requested an aging of identified overpayment adjustments and additional reporting on eligibility‑file issues that led to ineligible payments.