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County audit finds UMR claims administration largely accurate; small coding and manual errors corrected
Summary
A CTI audit of Kenosha County's UMR medical claims administration found the county "above the median" on financial accuracy and processing; auditors identified small coding/modifier and manual errors (including a weight‑loss surgery overpayment that UMR refunded) and recommended plan‑document clarifications.
County staff and Brown & Brown presented results of a CTI audit of UMR's 2024 claims administration to the committee, reporting generally positive results with limited, corrective findings.
Presenters said the audit combined a stratified random sample of 125 claims with a 25‑claim targeted review, an operational review and a plan‑document analysis. The audit checked whether contract terms were followed and whether claims were paid according to plan documents.
The random sample found a coding modifier typo that affected payments (adjusted by about $2,500), and the targeted review identified four issues: an incorrect payment for a weight‑loss surgery (UMR reimbursed the county), duplicate claim payment (about $50, corrected), and issues around durable medical equipment credits. CTI and UMR disagreed on some preventative services coding; presenters said members will not be billed and providers may resubmit corrected billing if they seek payment.
Presenters said about "91% of claims are auto adjudicated," limiting manual‑error exposure, and that overall financial accuracy and processing speed compared favorably with CTI's medians. Supervisors asked whether the audit covered prescriptions; presenters said drug claims were not part of this audit but could be considered in future reviews.
The committee accepted the presentation; presenters agreed to pursue plan‑document clarifications (for example, tobacco‑addiction language) and enhanced fraud/waste/abuse screening around identified concerns such as same‑day genetic testing without an office visit.
The county will review follow‑up documentation provided by UMR and consider whether to expand audit scope in a future budget cycle.
