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Healthcare Reform Law Saves Billions of Dollars for Self-Insured Plans: Have you Claimed Yours?

Self-insured health plans should seek to recover significant share from the billions of dollars in successful TPA’s anti-fraud recoveries according to recent federal court orders and public records from health insurance industry anti-fraud strategies.

Despite the fact the U.S. Healthcare Insurance industry is moving to re-classify premium dollars spent on anti-fraud expenses as medical care under PPACA MLR laws, any successful anti-fraud recoveries on behalf of self-insured plans nevertheless remain ERISA plan assets and must be disclosed and returned to the self-insured plans.

Industry anti-fraud recovery reports and federal court documents reveal successful antifraud recoveries are estimated to be in the billions of dollars.  Approximately 82.5% of large health plans are self-insured per DOL statistics.  Recent federal court rulings have confirmed that TPAs are prohibited under ERISA from concealing and retaining any hidden fees on behalf of the self-insured plan.   In addition to hidden fees any overpayment recoupments made from providers on behalf of self-insured plans are likewise plan assets and should be disclosed and returned to the self-insured plan.

On July 29, 2013, a federal court in Detroit, Michigan ordered a TPA to pay back a self-insured plan “$5,111,431, together with $914,241 in pre-judgment interest, and costs, post-judgment interest, and attorney fees”, after the court found the TPA engaged in ERISA prohibited transactions in violation of ERISA fiduciary duties, by concealment, fraudulent conducts and failing to return “hidden fees” or “PPO saving”.  The court documents further reveal the critical challenge in identifying “hidden fees”, especially in this case where, in spite of a “financially savvy” CFO, the TPA changed contract terminology numerous times.  Court Case Info: Hi-Lex Controls Inc v. Blue Cross and Blue Shield of Michigan, case #: 2:11-cv-12557-VAR-PJK, filed on 05/23/13 and 07/29/13, United States District Court Eastern District of Michigan.

Auditors, executives and fiduciaries of large self-insured health plans should look to educate themselves on the nuances of this national epidemic.  Hidden fees, anti-fraud overpayment recoveries or any other prohibited transactions with plan assets should be identified and returned to the plan.

Responsible parties must look to create clear policies and courses of action to ensure plan asset recovery practices. “Monitoring a service provider” and safeguarding plan assets are essential fiduciary duties according to the DOL Fiduciary Guidance: “Understanding Your Fiduciary Responsibilities Under A Group Health Plan”- http://www.dol.gov/ebsa/pdf/ghpfiduciaryresponsibilities.pdf.  Self-insured health plans that have changed service providers over the last two years should be particularly diligent in auditing for any of these prohibited transactions and should look for disclosures and their fair share of TPA’s successful anti-fraud recoveries.

In response to the immediate need for action Avym Corporation has created a series of seminars designed to assist self-insured plans identify and recover potential plan assets.  The seminars will review and examine the following issues:

To find out more about Self Insured Plan Tools and Services from AVYM please click here

District Court Rules against BCBSRI on Overpayment Recoupment and Withholding Tactics–Paves way for US Healthcare Overpayment Claim Denial Appeal Process

Federal court rules against BCBSRI in its overpayment recoupment and withholding lawsuit against healthcare providers: BCBSRI cannot recover money from past payments and cannot withhold money from future claims payments.

On May 22, 2013, the United States District Court for The District of Rhode Island ruled against BCBSRI in a landmark lawsuit for overpayment recoupment against two healthcare providers for alleged fraudulent billings.  Furthermore the court ruled in favor of the provider defendant’s counterclaims against BCBSRI for withholding monies from future claims.

In light of this landmark court decision, Avym Corporation offers advanced compliance webinars to examine the federal court’s judicial guidance on the nation’s most onerous healthcare provider claim denials: payor alleged overpayment refund demands from past payments and automatic withholding of future payments from other patients.

The training programs and policies advocated by Avym Corporation are one and the same that provided ERISA appeal compliance as well as fraud and abuse prevention assistance for the two defendant providers in this case.

Case Info: Blue Cross & Blue Shield Of Rhode Island v. Jay S Korsen And Ian D Barlow, Case#: 109-Cv-00317, Filed 05/22/13, United States District Court for The District of Rhode Island.

This case offers clear and authoritative legal guidance when dealing with the issues of overpayment demands to providers.   While relying upon relevant recent Supreme Court decisions, among other things, the court decided the following:

  1. Federal law ERISA is the only mechanism available to BCBSRI regardless of BCBSRI PPO contract;
  2. As a matter of ERISA law, BCBSRI can make no recovery for past payments and can withhold no money from future claims;
  3. Both healthcare providers were absolved of wrong doing as BCBSRI failed to present “clear and convincing evidence” to support fraud, medically unnecessary or mis-coding allegations;
  4. The two providers were not “given any opportunity to appeal or have Blue Cross’s determination reviewed, despite the inclusion of review procedures both under ERISA and the Provider (PPO) Agreements.”
  5. Whatever monies BCBSRI paid to both healthcare providers for alleged fraudulent billing and non-medically necessary treatments, rightfully, equitably, and in good conscience belongs to the providers;
  6. BCBSRI cannot recover the monies already paid out to the providers because those monies are not subject to equitable lien from the BCBSRI PPO contract overpayment provisions.
  7. The court rules for the provider’s counterclaims against BCBSRI for withholding money from future claims and orders BCBSRI to return all monies withheld from future claims with prejudgment interests and attorney fees to be determined by the court.

All employer sponsored health plans must comply with federal ERISA regulations when making demands for overpayment refunds.  According to industry estimates, the amount of money that payors seek to recover from providers through overpayment demands is in the billions of dollars.

A recent DOL court brief filed in federal appeals court for the 3rd Circuit also provides detailed regulatory interpretation of ERISA claim regulation for all overpayment disputes and appeals.  In all overpayment cases, a provider is entitled to insist upon its assigned right to challenge the allegedly wrongful decision to deny benefits through a process that complies with ERISA claims regulation

http://www.dol.gov/sol/media/briefs/tri3-enterprises(A)-11-30-2012.htm#.UMfi5z9MHFo

Avym Corporation offers advanced ERISA Compliance and Appeals training for both participating and non-participating hospitals, ASC’s and all providers, to appeal all overpayment denials, recoupment and withholdings or offseting, under the Court guidance in this case in compliance with ERISA and PPACA regulations.

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.

Medicare Anti-fraud Recovery Reaches $19 Billion; How Much for Private Self-Insured Plans? Is your third-party administrator holding out on you?

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.

2013 Emerging Trends for Out-Of-Network Health Claims: Total Claims Denial and Overpayment Recoupment

Out-of-network providers facing total claim denials and overpayment recoupment by individual payers with respect to every patient, every health plan and every claim due to provider’s failure to disclose self- referrals and routine cost sharing waivers.

Avym Corporation announces its 2013 special compliance assistance programs for out-of-network providers faced with overpayment recoupments in the millions of dollars and total claims denials by increasing number of payers with respect to every patient, every health plan and every claim.  These denials are allegedly due to provider’s failure to disclose self-referrals and/or routine cost sharing waivers among other fraud and abuse allegations, including breach of PPO contract, billing & coding errors, and medical necessity denials.

Based on the latest research in federal and state court records, Avym has developed the 2013 Out-Of-Network Healthcare Reimbursement model (OHR).  OHR will focus on compliance risk management and solutions for all out-of-network providers.  OHR will examine the most critical and emerging trend of 2013, total claim denials from multiple payers with respect to every claim.  Avym’s OHR model will examine the reasons for these total claim denials, specifically, if and when any one payer develops evidence that a provider allegedly fails to disclose the following:

  • Significant benefit interest and/or ownership;
  • Affiliation and remuneration (as required by federal and state laws);
  • Provider network status & UCR rates;
  • Patient out-of-network/out-of-pocket liabilities;
  • Patient’s freedom to choose an alternative facility;
  • Alleged routine waivers of patient deductibles, coinsurance and co-pays;

Such evidence may also be used against out-of-network providers and may be the genesis of endless lawsuits by private insurers or payers, and possible civil and criminal enforcement actions by governmental agencies.  In addition, these out-of-network providers may also face alleged overpayment recoupments or offsets by health plans for all new patients and new claims across multiple plans, patients and providers.

“More and more out of network providers and hospitals are experiencing total claim denials and overpayment recoupments by payers.  In 2013 it is likely that most out-of-network providers will face this crisis if they are not in compliance with all disclosure laws and patient cost-sharing (deductibles, coinsurance and co-pay) liability compliance,” said Vincent Flores, President and Co-Founder of Avym Corporation.

OHR and Overpayment Recoupment and Appeals Compliance Programs are available immediately, in provider specific, private formats.   These onsite programs consist of two-day fraud & abuse prevention and compliance seminars and /or two-day ERISA / PPACA appeal compliance seminars. The programs are specifically designed for out-of-network providers facing overpayment recoupments and total claim denials by payers as well as any in-network providers that have already received PPO termination letters.

Both programs are largely developed from the most recent federal and state court records, federal court decisions in nationwide provider UCR and overpayment class actions, DOL PPACA claims regulation guidance, HHS/OIG/CMS FAQ’s, OIG advisory opinions and DOJ/FBI press releases.

“In most cases, providers that are overly confident in these new payer challenges will most likely be taken by complete surprise by the payer’s total claims denial, victory in federal courts and then possible bankruptcy”, said Dr. Zhou, president of ERISAclaim.com, and a national expert on PPACA and ERISA appeals and compliance

According to the AMA news on June 25, 2012, “Aetna sues more physicians over out-of-network pay – The court fight is part of an ongoing battle between health plans and doctors over what constitutes fair health care bills.” http://www.ama-assn.org/amednews/2012/06/25/prsb0625.htm

As reported on 08-30-2012 by a Press Release from CMA, California Medical Association, “California Medical Association calls on Aetna to stop retaliatory behavior against physicians”. Dr. James T. Hay. M.D., CMA president, was quoted as saying: “Aetna is essentially saying that they will no longer do business with the 35,000 members of CMA.” http://www.cmanet.org/news/press-detail/?article=california-medical-association-calls-on-aetna

According To Houston Chronicle, November 7, 2012: “Federal Court Rules against BCBS in Overpayment ERISA Class Action: Providers Entitled to ERISA Appeal Rights http://www.chron.com/business/press-releases/article/Federal-Court-Rules-against-BCBS-in-Overpayment-3958959.php

The following main topics will be discussed in Avym’s 2013 special compliance assistance programs:

  1. Medicare recovery of $4.1 billion in 2011: “Health Care Fraud Prevention and Enforcement Efforts Result in Record-Breaking Recoveries Totaling Nearly $4.1 Billion” http://www.hhs.gov/news/press/2012pres/02/20120214a.html
  2. OIG Criminal and Civil Enforcement: https://oig.hhs.gov/fraud/enforcement/criminal/
  3. Health Care Fraud Prevention and Enforcement Action Team Provider Compliance Training: https://oig.hhs.gov/compliance/provider-compliance-training/index.asp
  4. DOL Affordable Care Act Regulations and Guidance: Internal Claims and Appeals and External Review: http://www.dol.gov/ebsa/healthreform/
  5. PCA v. BCBSA et. al. http://ww1.prweb.com/prfiles/2012/10/18/10028942/PCA%20v%20BCBSA.pdf

 

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