Payment Integrity Findings Report - Kentucky Employees' Health Plan | Second Quarter 2023

Summary of Findings

Analysis: HDS reviewed the Contract for Pharmacy Benefits Administration for the Kentucky Employee’s Health Plan, amendments and plan requirements documents to activate the appropriate HDS proprietary Claim Scans. These scans were supported by the KEHP Contracted Entity provided pharmacy network lists, drug lists, prior authorization files, and formulary documents. 

Findings: 

Resolution and Status from Errors Identified in the First Quarter:

• Insulin Cost Sharing Cap – The KEHP contracted entity is in the process of executing a service warranty which will provide reimbursement to impacted members for the overpayments on the associated claims.
• Claims paid at an amount greater than pharmacy usual and customary price – The KEHP Contracted Entity has agreed to execute a service warranty to have impacted claims appropriately identified and re-adjudicated within 90 days. KEHP agrees with HDS that the error potentially dates back to 01/01/2015, when the initial contract went into effect. The KEHP Contracted Entity has not provided documentation to support any claim paying at a price greater than usual and customary. The KEHP Contracted Entity is in the process of reviewing the scope of the error, which may be subject to further analysis and validation.
• Specialty Fee Schedule Pricing – Error has been agreed to for the amount above. A service warranty is in process.
• 340B claims – Will be categorized according to the KEHP contractual definition by utilizing a new pharmacy claims file format provided by the KEHP contracted entity. HDS will submit claims samples for review. Discrepancies Identified in the Second Quarter: Page 6 HealthPlan Data Solutions, Inc
• Multisource Brand Claims Rebill – HDS will provide the KEHP Contracted Entity with claims to review.
• Compound Claims Level of Effort – HDS requested a detailed compound data file from the KEHP Contracted Entity in May 2023 to assess the issues with the Level of Effort charges. HDS will evaluate the discrepancies when the files are provided.