Audit of claims of the United Nations health insurance plans administered by New York Headquarters

The United Nations Headquarters in New York offers comprehensive health insurance coverage including prescription drug coverage to its staff and retirees across the globe under five self-insured health insurance plans -- two US based medical plans, one US dental plan, and two medical/dental plan for staff serving elsewhere. Over 53,000 staff and retirees of the UN and its funds and programmes are enrolled in these plans with coverage also extended to their eligible dependants. The UN currently contracts with five separate third-party administrators (TPAs) under long-standing ASO agreements to administer health insurance claims on behalf of the Organization. The approximate breakdown of subscribers to these plans are: US plans Aetna (medical only): 5,000 Empire Blue Cross (medical only): 9,500 Cigna (dental only): 14,200 International plans Vanbreda (medical/dental): 19,600 Henner-GMC (medical/dental): 19,000 It should be noted that most of the subscribers to the Cigna dental plan are also enrolled in one of the two US medical plans. The UN is seeking to engage a consultant for the purpose of evaluating the accuracy and completeness of claims adjudication, assessing whether claims are processed in accordance with plan provisions and assessing whether the overall performance of the administrators meets desired operational standards. The target date for completion of the audits is 31 December 2013. The UN reimburses the TPAs on a periodic basis for claim payments effected. The conduct of the claims audits is driven by two principal concerns: (a) To ensure that the payments made by the carriers to providers and subscribers are for eligible plan participants, are fully supported by invoices/charges from providers, and reflect an accurate administration of the plan benefits. (b) To ensure that the contracted TPAs meet industry performance standards and that health insurance claims are processed in compliance with financial arrangements that are in place. The selected contractor shall: (1) Conduct five audits, i.e., separate audits for each of the self-insured US health plans administered by Aetna, Empire Blue Cross and Cigna, and for each of the self-insured international health plans administered by Vanbreda and Henner-GMC; (2) Determine adherence to procedures, and standard industry practices (i.e., verify payment accuracy and completeness of supporting documentation for processed claims); (3) Evaluate current claims processing performance in terms of market norms/practices (i.e., determine current performance levels including turn-around time and customer response time and established performance levels); (4) Evaluate effectiveness for fraud detection, anti-fraud procedures and control mechanisms; (5) Evaluate larger case management and medical interventions; (6) Evaluate correctness in interpretation of plan provisions; (7) Identify areas that are working well and opportunities for performance improvement