"A" = Actual Control "P" = Proposed Control
| CONTROLS | |||||||||||||||||||||||||||
| THREATS | C-1 City has current contract with PPO. | C-2 PPO has current contracts with providers. | C-3 City negotiates fixed rates for Kaiser/Lifeguard. | C-4 City has current contract with TPA. | C-5 City HRD sets TPA performance standards. | C-6 TPA hires experienced staff. | C-7 TPA uses employee performance measures. | C-8 TPA periodically gets actuarial UCR rate study. | C-9 TPA documentation of systems and procedures. | C-10 TPA computer access password controls. | C-11 TPA automated computer controls. | C-12 TPA automated management reports. | C-13 TPA manually logs all incoming/outgoing mail. | C-14 CSJEHP comprehensive plan document. | C-15 City Municipal Code. | C-16 City long-range plan for benefits. | C-17 City HRD periodically analyze plan costs. | C-18 City HRD periodically surveys provider rates. | C-19 City uses employees performance measures. | C-20 City monthly Benefits Review Forum. | C-21 City documentation of system & procedures. | C-22 City automated management reports. | C-23 City HRD review of TPA/City management reports. | C-24 City Payroll staff updates TPA eligibility database. | C-25 City HRD verifies student eligibility. | C-26 City HRD reviews large bills before payment. | C-27 City periodically re-enrolls plan members. |
| T-1 ELIGIBILITY - Eligibility listings are not complete, accurate, and properly updated. | A | A | A | A | A | ||||||||||||||||||||||
| T-2 PPO ALLIANCE - The PPO Alliance is not effectively negotiating fees with the hospitals and physicians that meet the City's specific needs and objectives. | A | A | A | A | A | ||||||||||||||||||||||
| T-3 PLANNING AND CONTROLLING HEALTH CARE COSTS - The City has not developed strategies addressing its health care needs (i.e., overall sttment of purpose, prioritized objectives, short-term action plan, long-term action plan, and measurable goals and obj | A | A | A | A | P | A | A | P | P | P | P | A | P | P | P | A | A | A | |||||||||
| T-4 ADMINISTRATION - The City is not effectively controlling and administering the City of San Jose Employee Health Plan; consequently, cost containment objectives may not result in savings. | A | A | P | P | P | A | P | P | A | A | A | ||||||||||||||||
| T-5 UTILIZATION - The Third Party Administrator's (TPA) Utilization Review Program does not ensure that the surgeries are appropriate, the length of stay appropriate , and the related charges are correct. | A | A | A | A | A | A | |||||||||||||||||||||
| T-6 THIRD PARTY ADMINISTRATOR - The City's TPA is not accurately an timely paying the claims in accordance with the provisions of the plan. | A | A | A | A | A | A | A | A | A | A | A | A | A | ||||||||||||||
| T-7 PRESCRIPTION DRUG PROGRAM - The City's TPA is not accurately and timely paying the prescription drug claims in accordance with the provisions of the plan. | A | A | A | A | A | A | A | P | P | ||||||||||||||||||
| T-8 MANAGEMENT REPORTS - The City is not receiving adequate detailed reports of medical claim activity or if adequate detailed reports are received, they are not being actively monitored and analyzed for effective management and control. | A | P | P | A | P |