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.