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Staff reviews cost summary, Rx rebates, claims‑integrity programs and cash reconciliation
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Summary
Presenters said Rx rebates and premium refunds partially offset plan overage; they described claims‑integrity programs (advanced review, subrogation) and proposed matching cash reconciliation reports to reduce timing discrepancies between paid claims and administrator reports.
David Babin reviewed the plan cost summary and highlighted several offsets and protections in the current year. He said the nine‑month Rx rebate total was roughly $2,588,235 and noted one‑time receipts: an Optum performance guarantee of $303,751 and a UnitedHealthcare premium refund of about $142,000 that are not counted in the presented plan‑year expenditures.
Babin described claims‑integrity programs that help reduce inappropriate payments, including advanced claims review and coordination of benefits, noting a recent advanced review that saved $44,000 by identifying undocumented CPT codes on a high‑cost claim. "These are the type of protections...that they're just not accepting these claims that come in," he said.
On cash reconciliation, staff showed that UMR aggregate reports and actual bank cash flows can differ by timing. Over a four‑month sample the paid amount was about $11,000,300 with a $37,542 variance likely explained by payment timing; staff proposed providing a reconciliation that matches the cash pulls to reduce the discrepancy.
Babin also flagged pending state pharmacy actions (Directive 257), which require PBMs to add a $9 dispensing fee at independent/local pharmacies and could shift costs to members or claims. He said staff will monitor legislative and administrative changes and analyze their effect on rebates and net plan cost.
