Archives March 2013

The Department of Health and Human Services and The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2012

Approximately 82.1% of large health plans (>500) are self-insured. 

With possibly more than $19 billion in anti-fraud and overpayment recovery by TPAs from healthcare providers in the private sector, how much has your self-insured plan received from your TPA’s Overpayment Recoupments?

On February 11, 2013, HHS and DOJ announced record-breaking anti-fraud recoveries of $4.2 billion for 2012, and $14.9 billion over the past four years.  Additionally, CMS has recovered $3.16 Billion in separate non-fraud overpayment recovery over the past three years.

http://www.hhs.gov/news/press/2013pres/02/20130211a.html

https://oig.hhs.gov/reports-and-publications/hcfac/index.asp

http://aspe.hhs.gov/health/reports/2011/LGHPstudy/index.shtml

“If Medicare contractors recovered $19 billion in anti-fraud and overpayment recoupments and failed or refused to return that $19 billion to Medicare and Medicaid, would those contractors be allowed to keep that money?  Likewise shouldn’t all private self-insured plans expect to reap a windfall from years of TPA antifraud and overpayment recoupments?” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert in ERISA and PPACA compliance, and a well-recognized expert in provider overpayment appeals and ERISA provider class action.

The question is very simple: with possibly more than $19 billion in anti-fraud and overpayment recovery from healthcare providers in the private sector, how much has your self-insured plan received from your TPA’s Overpayment Recoupments?

Avym Corporation (Avym) announces 2013 Fiduciary Overpayment Recovery programs for private self-insured health plans.  In 2011 private health insurance funded approximately 33% and Medicare funded approximately 21% of the $2.7 trillion national healthcare expenditure.  Approximately 82.1% of all large health plans (>500) are self-insured.  Avym’s innovative new programs consist of:

• The Fiduciary Overpayment Recovery Specialists (FOR) training program which is designed for private self-insured plans.
• The Fiduciary Overpayment Recovery Contractor (FORC) program which is designed to create partnership networks nationwide to immediately offer FOR programs to self-insured plans.

These groundbreaking programs are unique and unlike any other traditional health plan overpayment auditing programs and are designed to recover alleged overpayments, regardless of fraud allegations, that have been completely recouped by the TPA’s for whatever reason but have not been restored or refunded to the ERISA plan assets as required under ERISA statutes and fiduciary responsibilities.

Most recent federal anti-fraud investigations, indictments, settlements and court orders result in adverse outcomes for providers, typically as payments and penalties to Medicare and Medicaid as well as private health plans.   Most private health plan TPA’s overpayment recoupment practices are not as transparent or public as the Medicare or Medicaid programs and typically involve automatic and silent recoupment from providers on both previous patients and new patients.

http://www.hhs.gov/news/press/2012pres/07/20120726a.html

https://oig.hhs.gov/fraud/enforcement/criminal/

It is estimated by industry experts $19 billion may pale in comparison to what may have been recovered in the private sector over the past three or four years.  Alleged anti-fraud settlements with sweeping federal and state antifraud enforcement, unreported nontransparent automatic recoupment from providers and silent offsetting or withholding are all contributing factors.  The Institute of Medicine claims that “about 30 percent of health spending in 2009 — roughly $750 billion — was wasted on unnecessary services, excessive administrative costs, fraud, and other problems”. http://www8.nationalacademies.org/onpinews/newsitem.aspx?recordid=13444

The following OIG overpayment audit reports for governmental programs were instrumental in the FOR programs design and launch:

OIG of U. S. Office of Personnel Management: “Audit of Bluecross Blue Shield Association Washington, DC and Chicago, Illinois”, March 6, 2012,

“The Association’s FEP Special Investigations Unit (SIU) is not in compliance with Contract CS 1039 and the FEHBP Carrier Letters issued by the Office of Personnel Management (OPM) related to F&A Programs and notifying OPM’s Office of the Inspector General of F&A cases in the FEHBP.” http://www.opm.gov/our-inspector-general/reports/2012/final-report-no-1a-10-91-11-030-bcbs-association-in-washington-dc-and-chicago-illinoi-_redacted.pdf

HHS OIG Report: “Delaware Did Not Comply With Federal Requirements To Report All Medicaid Overpayment Collections”, 06/22/2012

“We found that Delaware did not comply with Federal requirements to report all Medicaid overpayment collections. Of the $16.29 million Medicaid overpayments collected, the State failed to report $16.27 million ($10 million Federal share). State officials said that they believed the overpayments had been netted out of reported Medicaid expenditures but did not provide support for such an adjustment.” https://oig.hhs.gov/oas/reports/region3/31100203.asp

DOL Fiduciary Compliance Guidance: “Meeting Your Fiduciary Responsibilities:

“With these fiduciary responsibilities, there is also potential liability. Fiduciaries who do not follow the basic standards of conduct may be personally liable to restore any losses to the plan, or to restore any profits made through improper use of the plan’s assets resulting from their actions.” http://www.dol.gov/ebsa/publications/fiduciaryresponsibility.html

Self-Insured Plan TPA recoupments, which can reach 30% of annual plan healthcare expenses, must be refunded to self-insured plans in a timely manner.  Otherwise plan assets could be exposed to huge losses and Plan Administrators can be exposed to incredible fiduciary liability.

To find out more about PPACA Claims and Appeals Compliance Services from AVYM please click here.

Located in Los Angeles, CA, Avym is a leading provider of services focusing entirely on the resolution of denied or disputed medical insurance claims by participating in the nation’s first ERISA/PPACA Claims Appeals Certification program. Avym also offers webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support.

On March 1, 2013, the Department of Labor (DOL) released new and detailed PPACA self-compliance guidance for full implementation of PPACA Coverage and Claims Appeals Regulations, also known as the Provider Bill Of Rights.  Healthcare Providers as well as Health Plans are urged to comply with PPACA in accordance with DOL’s Self Compliance Guidance, the most comprehensive “Self Compliance Tools” for the nation’s health plans and healthcare providers since the Supreme Court upheld PPACA’s constitutionality on June 28, 2012.

In conjunction with the DOL’s issuance, Avym announces unique PPACA claim appeals compliance programs for BOTH healthcare providers and health plans, as intended by Congress to protect all patients under the Patient Protection and Affordable Care Act.  PPACA is also known as the Patient Bill Of Rights by Congress and the White House.  With the DOL’s self-compliance guidance and particularly the claims denial and appeals protections, PPACA can now be defined as the “Provider Bill of Rights” under PPACA claims regulation.

In issuing these comprehensive PPACA Self Compliance Tools, the DOL has stated the scope and importance of PPACA compliance for everyone: “This self-compliance tool is useful for group health plans, plan sponsors, plan administrators, health insurance issuers, and other parties to determine whether a group health plan is in compliance with some of the provisions of Part 7 of ERISA….. Under the Affordable Care Act, there are various provisions that apply to group health plans and health insurance issuers and various protections and benefits for consumers that are beginning to take effect or that will become effective very soon.”

http://www.dol.gov/ebsa/healthlawschecksheets.html

The entire DOL Self Compliance Tools may be found at DOL website:

http://www.dol.gov/ebsa/pdf/part7-1.pdf

http://www.dol.gov/ebsa/pdf/part7-2.pdf

PPACA coverage and claims appeals regulations provide expanded consumer coverage and claims denial and appeal protections. PPACA adopts ERISA (the federal law in existence for 37 years) in its entirety as the minimum internal appeals standards, with additional consumer and provider protections. PPACA also provides federal external appeal protections. DOL PPACA and ERISA self-compliance tools are in forms of the most comprehensive questions for health plan payers to determine compliance according to DOL:

“Internal Claims and Appeals

Under the Affordable Care Act group health plans and health insurance issuers offering group health insurance coverage were required to implement an effective internal claims and appeals process for plan years beginning on or after September 23, 2010. In general, the interim final regulations require plans and issuers to comply with the DOL claims procedure rule under 29 CFR 2560.503-1 and impose specific additional requirements and include some clarifications (referred to as the “additional standards” for internal claims and appeals). In addition to meeting the following requirements, the plan is required to comply with all of the requirements of the DOL claims procedure rule under 29 CFR 2560.503-1.

The following questions have been developed to assist in determining compliance with the additional standards for internal claims and appeals processes.”

http://www.dol.gov/ebsa/pdf/part7-2.pdf

With respect to Providers Bill of Rights, one of the most important new PPACA protections for all providers, according to the DOL, is the following:

“Question 2 – Does the plan provide claimants with any new or additional evidence or rationale considered in connection with a claim?

The Department’s regulations clarify that plans or issuers must provide to claimants, free of charge, any new or additional evidence considered, relied upon, or generated by (or at the direction of) the plan or issuer in connection with a claim. This evidence must be provided as soon as possible and sufficiently in advance of the date on which the notice of final internal adverse benefit determination is required to be provided in order to give the claimant a reasonable opportunity to respond prior to that date. Similarly, before a plan or issuer can issue a final internal adverse benefit determination based on a new or additional rationale, the claimant must be provided, free of charge, with the rationale. This rationale must be provided as soon as possible and sufficiently in advance of the date on which the notice of final internal adverse benefit determination is required to be provided in order to give the claimant a reasonable opportunity to respond prior to that date. See 29 CFR 2590.715-2719(b)(2)(ii)(C).

This provision is applicable for plan years beginning on or after September 23, 2010. See 29 CFR 2590.715-2719(g).” http://www.dol.gov/ebsa/pdf/part7-2.pdf

The new Avym PPACA training partnership programs will explore possibilities to:

1. Create partnership networks nationwide to immediately offer Certified PPACA & ERISA Claim Specialist Programs, same as Medicare claims and compliance for 45 years;
2. Create awareness and readiness to develop a national network or association for PPACA & ERISA Claim Specialists.

To find out more about PPACA Claims and Appeals Compliance Services from AVYM, please click here.

Located in Los Angeles, CA, Avym is a leading provider of services focusing entirely on the resolution of denied or disputed medical insurance claims by participating in the nation’s first ERISA/PPACA Claims Appeals Certification program.  Avym also offers webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support.