Category Employer Health Reform

On July 16, 2012, California Department of Managed Health Care ordered Anthem Blue Cross to stop trying to collect millions in reimbursement from providers for medical claims the health plan thinks were overpaid.

Avym announces free executive webinars designed to examine the California Department of Managed Health Care’s order and discuss the profound impact of the entire overpayment recoupment market, estimated to be in the billions of dollars.

State regulators ordered Anthem Blue Cross on July, 16 2012 to stop trying to collect millions in reimbursement from providers for medical claims the health plan alleges were overpaid.

California State law allows health plans to seek reimbursement for overpaid medical claims within a year of the payment date. In order for a plan to collect on claims more than a year old, it must demonstrate fraud or misrepresentation by the provider.

Earlier this year, the California Department of Managed Health Care (DMHC) investigated collection attempts by Anthem Blue Cross between 2008 and 2011 and found the plan tried to collect overpayments from at least 535 providers for claims that were more than a year old. Anthem did not provide evidence of fraud or misrepresentation, the agency said in a news release Monday.

The plan alleged providers had improperly coded the claims using upcoding, unbundling or miscoding procedures, the cease-and-desist order shows.

Anthem, which is based in Thousand Oaks, CA, tried to collect payments from another 13 providers who allegedly had billed for services they had not rendered.

“Health care providers should not face unexpected demands for reimbursement of medical claims they believe were appropriately paid years ago,” agency director Brent Barnhart said in the release. “Anthem’s recoupment practices violate California law and are unfair to providers who are acting in good faith.”

Anthem spokesman Darrel Ng stressed in a prepared statement that the issue does not involve patient care or safety: “The issue is about Anthem Blue Cross’s efforts to keep health care affordable,” he said. “Anthem Blue Cross believes medical providers should be compensated for services provided, but should not receive payment twice for the same procedure.”

According to Mr. Ng, Anthem sought reimbursement for overpayments due to double billing which is consistent with guidelines from the American Medical Association.  “We will closely examine today’s action by DMHC and are considering our options,” he said.

Many providers are still trying to figure out what to do in light of the DMHC’s order.  The California Medical Association (CMA), which made the initial request to the DMHC to investigate, issued a press release urging the DMHC to take further action, including imposing heavy fines to deter future abuses. CMA is also asking DMHC to require Anthem refund to physicians any overpayments collected in violation of the law.

No decision has been made about whether the collected alleged overpayments will have repaid, but DHMC offered this advice: If a provider receives (or has received) a notice from Anthem (or any plan) requesting recoupment of alleged overpayments from claims older than one year, they should first file an appeal with the plan. If the appeal is unsuccessful, the plan is non-responsive or they are unsatisfied with the response, the provider should file a complaint with the DMHC Provider Complaint unit at: http://www.dmhc.ca.gov/providers/clm/clm_comp.aspx

This comes on the heels of Anthem’s recent troubles with the CA DMHC.  In January of 2012, Anthem was ordered pay doctors and hospitals money owed for services going back to 2007.  The action is a result of Anthem’s refusal to remediate providers following a financial claims audit that identified errors in payment of medical claims

This is in addition to a lawsuit, intended to be a class action, filed by consumer advocate group Consumer Watchdog.  the complaint challenges alleged “bait and switch” tactics affecting more than 100,000 individual plan members hit by deductible increases and other changes in May. It also targets other changes that allow Blue Cross to alter terms of health plan contracts several times in a year, with 60 days’ notice.

What does this mean to overpayment request by payors?  AVYM offers free webinars that will examine the importance of appealing overpayment requests, including an analysis of the GAO Report findings “When denied reimbursement by an insurance company, one of the biggest mistakes made is not appealing the decision. When denied reimbursement for services you have the right to appeal and the Insurance Company/Plan Administrator is required to explain why they denied the claim. Doing so often pays off, with an estimated 59 percent of appeals being decided in favor of the claimant.”

Avym webinars will:

• Focus on the number one healthcare dispute right now in the U.S. against health plans, providers and patients as well as the relevance of recent US Supreme Court decisions and their effects on claims denials, audits, and litigation of claim disputes. 77% of insured Americans under employer sponsored health plans are affected by these issues;
• Analyze the new federal health reform law, PPACA claim regulations, which have adopted ERISA law as the minimum claim regulations standard for all health plans which now includes individual market claims outside of Medicare;
• Analyze and discuss ERISA claim regulation which, for the last 36 years, has provided very specific provisions regulating the “circumstances which may result in disqualification, ineligibility, or denial or loss of benefits”;

To find out more about ERISA/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 free 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 June 12, 2012, According to a unit of UnitedHealth Group Inc., (NYSE: UNH) it will “will stick with some of the patient relationship requirements set by the federal Patient Protection and Affordable Care Act of 2010 (PPACA) no matter what the U.S. Supreme Court concludes about the constitutionality of the law.”

“UnitedHealthcare also will continue to follow the new appeals process standards”.

The Patient Protection and Affordable Care Act (PPACA) was signed into law by President Obama on March 23, 2010.  PPACA claims regulations will govern all claims processing, reimbursement, denials and appeals for almost all healthcare claims outside Medicare: ERISA claims and non-ERISA claims as well as all individual policies.  PPACA claims regulations adopted ERISA claims regulation in its entirety as PPACA internal appeals process, and adopted NAIC’s external model as PPACA external appeals process.

If a health plan fails to strictly adhere to all requirements of the new federal appeals regulations, claimants who appeal have immediate and powerful protections and remedies which include expedited external appeals, continued coverage and Lawsuits (including possible monetary damages).  These regulations set forth six new requirements in addition to those in the DOL claims procedure regulation:

• Clarification of meaning of adverse benefit determination
• Expedited notification of benefit determinations involving urgent care
• Full and fair review
• Avoiding conflicts of interest
• Notice (New EOB Standards)
• Deemed exhaustion of internal claims and appeals processes.

According to a White House Press Examiner release, among the provisions that UnitedHealth will continue to promote are  “Providing Clear and Timely Options for Appeals-UnitedHealthcare will continue to ensure that consumers are offered a simple, accessible external appeals channel and a process that is clear and timely. The company will give consumers notice of available appeals processes and the opportunity to review their files and present evidence as part of the appeals process.”

UnitedHealth President, Stephen Hemsley, stated that “that the company is voluntarily agreeing to keep the standards because the standards promote access to quality care and can help control health care costs.”

(http://www.examiner.com/article/unitedhealthcare-will-offer-obamacare-regardless-of-the-us-supreme-court-ruling)

On June 13, 2012, Humana Inc. (NYSE: HUM) announced that it will also maintain important health care insurance protections that were included in the 2010 health care reform law, no matter how the U.S. Supreme Court rules in the case pending before the Court. Humana is the second major health insurance provider to authenticate The Patient Protection and Affordable Care Act (PPACA).

Among the PPACA provisions Humana will continue to enforce are ERISA PPACA appeals rules: “Humana will continue to provide a clear and simple process for appealing claims decisions, as well as the option for health plan members to have their cases reviewed by independent review organizations. Humana believes in providing a clear, timely and accessible avenue for health plan members to appeal and resolve disagreements.”

(http://www.examiner.com/article/humana-will-also-offer-obamacare-regardless-of-the-us-supreme-court-ruling)

On June 14, 2012, AETNA joined UnitedHealth and Humana in pledging to keep key elements of the PPACA.  Even as more companies are expected to follow suit, the three companies pledge that regardless of how the U.S. Supreme Court rules in the case currently pending before the Court, major provisions will remain part of the coverage.

According to the latest White House Press Examiner release, among the specific provisions that will be extended by UnitedHealthcare, Humana, and Aetna is the provision that provides clear (and timely) options for appeal.

(http://www.examiner.com/article/aetna-joins-unitedhealthcare-and-humana-pledge-to-keep-portions-of-obamacare)

In spite of the fact that the U.S. Supreme Court is expected to rule shortly about the constitutionality of the act, more healthcare insurance providers, in addition to the three already announced, are expected to follow suit and adopt the same major portions of the law.

AVYM offers free webinars that will examine the importance of appealing denied claims, including an analysis of the GAO report findings “When denied reimbursement by an insurance company, one of the biggest mistakes made is not appealing the decision. When denied reimbursement for services you have the right to appeal and the Insurance Company/Plan Administrator is required to explain why they denied the claim. Doing so often pays off, with an estimated 59 percent of appeals being decided in favor of the claimant.”

Avym webinars will:

• Focus on the number one healthcare dispute right now in the U.S. against health plans, providers and patients as well as the relevance of recent US Supreme Court decisions and their effects on claims denials, audits, and litigation of claim disputes. 77% of insured Americans under employer sponsored health plans are affected by these issues;

• Analyze the new federal health reform law, PPACA claim regulations, which have adopted ERISA law as the minimum claim regulations standard for all health plans which now includes individual market claims outside of Medicare;
• Analyze and discuss ERISA claim regulation which, for the last 36 years, has provided very specific provisions regulating the “circumstances which may result in disqualification, ineligibility, or denial or loss of benefits”;

To find out more about ERISA/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 free 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.

Court Dismisses Aetna’s Landmark “$99,750 Ear Wax Fraud” Lawsuit Against Out Of Network (OON) Hospital And Two Surgeons In Hospital’s Patient Discount Practice. Avym Corporation Offers Webinars To Examine Impact On Patient’s Right To Choose And New Wave Of Litigation By Payors.

On 04-13-2012, a Texas Court dismissed Aetna’s landmark “$99,750 Ear Wax Fraud” case against an out of network (OON) hospital and two surgeons, Aetna’s lawsuit alleged that the hospital charged $99,750 for ear wax removal.  Aetna was seeking temporary injunction to stop the hospital’s patient discount practice of not collecting full deductible and co-insurance from all patients. The Court dismissed the entire Aetna lawsuit after Aetna voluntarily filed a Notice of “Plaintiff’s non-suit without prejudice”. As a result of the dramatic court proceedings for the defendant hospital and two surgeons Avym announces new Webinars to examine this breaking development.

According to the Court document filed on 04-13-2012, Aetna “announced to the Court that they no longer wish to pursue any of the claims asserted by them against Defendants Ifeolumipo O. Sofola, M.D., Navin Subramanian, M.D. and Humble Surgical Hospital, LLC. This non-suit terminates the case upon filing”.

The Court Case info: AETNA HEALTH INC vs. SOFOLA, IFEOLUMIPO O (MD) (Case #: 2011-73949 / Court 152)

Avym Corporation offers webinars to examine the impact of this landmark 2012 healthcare case.  The core issue of these lawsuits is the patient’s rights to choose.  Recently there has been a wave of payor litigation nationwide over provider’s patient discount practice.  According to Govt. statistics more than 77% of insured Americans in the private sector pay for the right to receive care from out-of-network providers and facilities.  This Court decision, along with all other pending Aetna cases across the nation, is very important for the 77% of insured Americans in the private sector with out-of-network coverage.

On Dec 7, 2011, Aetna filed this lawsuit in the District Court, Harris County, Texas. Aetna lawsuit seeks for temporary injunction to stop the hospital’s patient discount practice and PPO surgeon’s OON referrals, alleging breach of contract, conspiracy to overcharge, tortious interference, and common law fraud, including “a bill for $99,750 for the removal of ear wax”.

On Feb. 02, 2012, Aetna filed a “$66,100 bunion surgery” lawsuit in California against seven California surgery centers, seeking to stop the alleged UCR billing without collecting full deductible and co-insurance from all patients. The court case info: Aetna Life Insurance Co. v. Bay Area Surgical Management LLC, File 02/02/2012, Case #: 112CV217943, The Superior Court of California, County of Santa Clara.

According to the Crain’s New York Business on Feb. 07, 2012, Aetna also quietly filed similar lawsuits last year in the State of New Jersey and New York against several out-of-network doctors for allegedly aggressive collections from out of network patients.(http://www.crainsnewyork.com/article/20120207/HEALTH_CARE/120209916)

According to a Bloomberg Businessweek article: “Harvard researchers say 62% of all personal bankruptcies in the U.S. in 2007 were caused by health problems—and 78% of those filers had insurance”.
(http://www.businessweek.com/bwdaily/dnflash/content/jun2009/db2009064_666715.htm)

In addition, on March 7, 2012, NY State Governor Andrew M. Cuomo announced that the Department of Financial Services (DFS) is investigating unexpected out-of-network medical costs affecting New Yorkers across the state, many of whom cannot afford to pay out-of-pocket expenses. DFS released a report finding that insurance companies share the burden of responsibility with healthcare providers for unexpected out-of-pocket expenses driving so many patients into bankruptcy. “The report finds an overwhelming need for increased transparency from insurers and medical service providers, and improved consumer protection measures to ensure that New Yorkers stop receiving unexpected bills.” (http://www.dfs.ny.gov/about/press/pr1203071.htm)

According to the Press release on 03/07/2012 from NY State Governor Andrew M. Cuomo:

“Insurers are paying less of the cost of out-of-network care: The investigation found that insurers are moving to a system that greatly increases how much it costs consumers when they are treated out-of-network. To determine what they would pay for out-of-network care, most insurers used to use what is known as the usual and customary rate (UCR), which is supposed to be an average of actual bills for a procedure in that region. But now most are using the Medicare rate, which decreases how much insurers pay by as much as half or more in some cases. Insurers make this change hard for consumers to understand, because some are told they are going from 80% of the usual and customary rate to 140% of Medicare, which sounds like an improvement, but is not.”

Avym Corporation Webinars will cover Aetna’s legal arguments of fraud allegations and compliant patient discount practices.  Avym will also discuss out of network referral practices in relation to patient’s ability to exercise informed choices.

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 free 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.

“The U.S. Department of Justice has announced Tampa, Fla.-based WellCare Health Plan will pay $137.5 million to the federal government and nine states to settle four lawsuits alleging the payor violated the False Claims Act.

The suits claim WellCare committed a number of schemes to submit false claims to Medicare and Medicaid programs. Allegations include WellCare inflating the amount it claimed to spend on medical care, knowingly retaining overpayments it received from Florida Medicaid for infant care and falsifying data to misrepresent patient conditions and treatments.

The $137.5 million settlement will be divided among the federal government and nine states: Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Missouri, New York and Ohio. Sean Hellein, a financial analyst formerly employed by WellCare whose qui tam complaint initiated the federal investigation, will receive approximately $20.75 million.

Recently, in a separate ongoing case:

United States District Court of New Jersey denied UnitedHealth’s (UHC) motion, in its entirety as to all claims, to dismiss the providers’ ERISA class action alleging that UHC’s wrongful overpayment recoupment is in violation of federal law.  The insurance practice of overpayment recoupment has been and is becoming a larger legal and financial challenge for health plans, healthcare providers and patients to overcome. Almost all health care providers have been affected by an overpayment dispute over the past few years and according to industry estimates, more than 50% of the $2.6 trillion in annual US healthcare expenditure is subject to overpayment dispute.

What does this mean to overpayment request by payors?

In accordance with recent developments, Avym Announces 2012 Free Webinars And Plan Assets Recovery Programs To Assist Self-Insured Health Plans Recover Hundreds Of Millions Of Dollars In Plan Assets From Successful TPA’s Overpayment Recovery.  More Than 60% Of TPA Recovered Money Originated From Self-Insured Plans And Should Be Returned To Self-Insured Health Plans Under New DOL Contributory Plans Criminal Project.

Avym Announces 2012 Free Webinars And Plan Assets Recovery Programs To Assist Self-Insured Health Plans Recover Hundreds Of Millions Of Dollars In Plan Assets From Successful TPA’s Overpayment Recovery.  More Than 60% Of TPA Recovered Money Originated From Self-Insured Plans And Should Be Returned To Self-Insured Health Plans Under New DOL Contributory Plans Criminal Project.

Avym announces 2012 free webinars and plan assets recovery programs designed to assist self-insured health plans potentially recover hundreds of millions of dollars in plan assets from successful TPA overpayment recovery efforts.  According to industry estimates, TPA successful overpayment recovery reaches into the billions of dollars nationwide over the past 5 to 7 years.

More than 60% of national TPA recovered money initially originated from self-insured plans and should be returned to those same self-insured health plans.  Every plan fiduciary has statutory duties to safeguard plan assets: to audit all alleged overpayments by TPA’s and to recover every dollar in plan assets when there were known successful overpayment recoveries by the TPA’s.  Avym offers this unique and powerful Plan Assets Recovery Program for the purpose of compliance assistance under new DOL Contributory Plans Criminal Project.

02/23/2011: DOL EBSA News Release:

Morrow, Ohio-based third-party plan administrator pleads guilty to embezzlement of $1 million from retirement plan clients [02/23/2011]

“The third-party administrator to 56 employee benefit plans — most covered by the Employee Retirement Income Security Act — located throughout Ohio and several other states pleaded guilty to one count of embezzlement of $1 million in assets from 12 retirement plans.”  

“This defendant’s theft of employee benefit assets jeopardized the retirement security of workers covered by these plans. This crime is particularly egregious in light of the duty of plan officials and service providers to protect plan assets from abuse,” said Phyllis C. Borzi, assistant secretary of the Labor Department’s Employee Benefits Security Administration.”  http://www.dol.gov/opa/media/press/ebsa/EBSA20110228.htm

During the last 7 years, there have been industry wide reports of successful healthcare anti-fraud and overpayment recovery in the billions of dollars.  On November 16, 2010, U.S. Labor Department announced nationwide enforcement actions to protect millions of dollars in worker retirement and health benefits. http://www.dol.gov/ebsa/newsroom/2010/10-1614-NAT.html

DOL EBSA: Contributory Plans Criminal Project Fact Sheet States:

“Millions of American workers share in the costs of employee benefits by contributing to employer sponsored retirement and health benefit plans. In 2010, the Department of Labor’s Employee Benefits Security Administration (EBSA) initiated the Contributory Plans Criminal Project (CPCP) to combat criminal abuse of contributory benefit plans.” http://avym.com/dol-ebsa-contributory-plans-criminal-project-fact-sheet/

It is simple and clear -when a contributory benefit plan initially overpays millions of dollars due to TPA’s errors, and several years later, the same TPA recovers said overpayment in its anti-fraud operation, such recovered money should be returned to the self-insured health plans, and must not be converted or embezzled into the TPA assets.

Avym Webinars are designed to assist self-insured health plans comply with ERISA fiduciary laws by safeguarding contributory plan assets, and to assist with DOL EBSA Contributory Plans Criminal Project:

“EBSA works closely with other federal, state, and local agencies to enforce laws safeguarding contributory plan assets. Criminal prosecution of individuals who abuse their authority or control over contributory plans can result in severe criminal penalties, including imprisonment. Those convicted of embezzling or misappropriating moneys intended to fund pension plans or pay health benefits typically are barred from providing services or acting in any capacity for a period of 13 years.” http://avym.com/dol-ebsa-contributory-plans-criminal-project-fact-sheet/

Avym Webinars are free to all self-insured ERISA plans.  Webinars are designed to review industry facts and applicable federal laws, and explain how and why a self-insured ERISA health plan should be refunded by its TPAs for recouped overpayment money.  These free webinars are scheduled for 30 minutes each session.  To schedule a free webinar, or for more information contact us at: info@avym.com

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 free 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.