PEBP accepts CTI audit findings of UMR and authorizes collection of 1% penalty
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Summary
A quarterly CTI audit of UMR found financial and procedural errors; the board accepted the audit, authorized collection of a 1% administrative penalty ($14,677.71), and directed staff to pursue recoveries and process improvements with UMR and CTI.
The Public Employees Benefits Program Board accepted a Q1 FY26 audit conducted by Claim Technologies Incorporated (CTI) on Jan. 20 and authorized staff to collect the associated administrative penalty.
CTI auditor Joni Amato reviewed claims processed from July 1 through Sept. 30, 2025, noting approximately $75.9 million in paid claims across roughly 244,000 claims. The random‑sample audit identified a small number of financial errors (including overpayments) and one nonfinancial error; targeted testing found duplicate payments, plan exclusion issues, prior‑authorization noncompliance, and copay application errors. CTI also flagged a procedural inconsistency: UMR is applying a $750 emergency‑room copay in some cases when a member is subsequently admitted, even though the MPD language says the copay should be waived if the visit results in admission. CTI recommended reviewing the procedure or updating MPD language.
UMR representatives (Jennifer Spencer and others) told the board that they review audit findings, have existing safeguards, and will implement targeted coaching or system programming changes where necessary. UMR agreed to provide clearer documentation of remediation steps in response to the audit recommendations.
Therese Karsten reported follow‑up on an earlier CTI overpayment figure (~$2.5M): UMR found that approximately $1.7M of the prior total related to newborn eligibility and data lags; those claims were actually eligible and the revised CTI overpayment total is about $825,000. The board authorized staff to work with UMR and CTI on future audits and feedback.
The board approved acceptance of the audit and the 1% administrative fee penalty (listed in the CTI report as $14,677.71) and directed staff to collect the penalty and pursue recoveries and process improvements. No systemic failures were identified that required immediate contract termination; UMR said prior edits and duplicate‑claim flags have been or will be strengthened and that any necessary programming or processor training will be implemented.
The board’s action: accept audit, authorize penalty collection, and ask staff to return with documentation of remediation progress.
