The insurance enrollment process appears to be timely and accurate, the average health insurance claim appears to be processed in a timely fashion, and, with one exception, fraud controls are in place. However, our survey work did identify two concerns regarding the accuracy of claim payments and the need for additional fraud controls within the pharmacy division. PEHP's Claims Processing Quality Can Improve. The quality of claims processing at PEHP can improve. Both the medical and dental programs have error rates which are higher than PEHP desires.
Error rates measure the percent of claims processed which contain payment errors.
Pharmacy Needs To Consider Additional Controls. The pharmacy division should consider adding controls to reduce the possibility of billing errors and pharmacy fraud. Other pharmacy insurers and PEHP divisions use procedures which the pharmacy division might consider adopting as possible controls.