Health Insurance Industry Watchdog and Others, Starting to See the Light
As more and more federal cases involving medical claim reimbursement disputes make their way through the courts, it is becoming increasingly clear that ERISA regulations will continue to pave the way for providers. However, ERISA can also pave the way for employers as well. Recently, a health insurance industry watchdog wrote about a very important development in the US Health Insurance Industry that I have been writing about since 2012. The case is Hi-Lex Controls, Inc. v. Blue Cross Blue Shield of Michigan.
The details of the case are fairly simple. BCBS Michigan was the claims administrator for multiple self-insured plans and had been charging the plans “hidden fees” by essentially adding markups to the medical claims submitted to the self insured plans. The problem was that BCBS Michigan never disclosed the markups.
“In the healthcare provider arena the No. 1 health care claim denial in the country today is the overpayment recoupment and claims-offset. Correspondingly, for self-insured health plans, the No. 1 hidden cost is overpayment recoupment and plan assets embezzlement.”
In May of 2014, the 6th Circuit Court of Appeals upheld the district court’s $6.1 million award against BCBS Michigan Michigan for violating ERISA’s rules regarding prohibited transactions and fiduciary fraud. The federal courts agreed that federal ERISA law prohibits BCBS Michigan’s TPA self-dealing as an ERISA fiduciary by withholding all hidden fees or overpayment recoveries. In September of 2014, BCBS Michigan, along with other insurance industry lobby groups, filed a petition to the US Supreme Court, requesting a hearing to challenge the 6th Circuit’s decision. The Supreme Court refused the request, on October 20 2014, thereby upholding the circuit courts decision. On November 5, 2014, only 15 days after the high court’s denial of BCBSM’s appeal, a federal district court in Michigan lifted a previous stay order for one of the more than 50 similar pending cases.
“The immediate impact of the Supreme Court’s decision could be billions of dollars for all self-insured ERISA health plans nationwide, as a result of the TPA industry’s potential recovery of a billion dollars in overpayment recoupments and anti-fraud campaigns over the past 10 years.”
As illustrated by the Supreme Court decisions and the reopening of similar cases, it is extremely critical for all self-insured health plans and TPAs to understand the implications of the Supreme Court decision rejecting BCBSM’s $6.1 million appeal. Furthermore, in accordance with the Supreme Court Hi-Lex decision and the reopening of pending cases, all self-insured health plans nationwide should look to recover at least $30 to $45 billion in Plan Asset refunds from the past 10 years of successful plan assets TPA/ASO anti-fraud recoupments and managed care savings in the private sector.
Avym Corporation announces new advanced ERISA Embezzlement Recovery Programs in preparation of the forth-coming Supreme Court decision, which will have a multi-billion dollar impact on self-insured health plans nationwide. Specifically the advanced programs will examine the following issues: (1) determine if any TPA overpayment recoupments and offsets, which are in the billions of dollars nationwide, are ERISA plan assets, (2) ensure all TPA’s properly refunded ERISA plan assets as ERISA prohibits all self-dealings, (3) communicate and clarify self-insured plan administrator’s potential liability for fiduciary breach in failing to safeguard or recover plan assets.
These groundbreaking TPA/ASO auditing programs are unique and unlike any other traditional self-insured health plan overpayment auditing programs and are designed to identify and recover alleged overpayments that have been recouped by the TPAs –but have not been disclosed, restored or refunded to the ERISA self-insured plan assets as required under ERISA statutes and fiduciary responsibilities. All self-insured health plans and TPAs should monitor this extremely critical Supreme Court decision on the BCBS appeals, in view of the fact that almost every TPA for self-insured health plans has engaged in successful overpayment recoupment and offsetting from healthcare providers in today’s multibillion-dollar overpayment recovery and offset industry.
In the healthcare provider arena the No. 1 health care claim denial in the country today is the overpayment recoupment and claims-offset. Correspondingly, for self-insured health plans, the No. 1 hidden cost is overpayment recoupment and plan assets embezzlement. The immediate impact of the Supreme Court’s decision could be billions of dollars for all self-insured ERISA health plans nationwide, as a result of the TPA industry’s potential recovery of a billion dollars in overpayment recoupments and anti-fraud campaigns over the past 10 years.
For over 6 years, Avym Corp. has advocated for ERISA plan assets audit and embezzlement recovery education and consulting. Now with the Supreme Court’s guidance on ERISA anti-fraud protection, we are ready to assist all self-insured plans recover billions of dollars on behalf of hard-working Americans. To find out more about Avym Corporation’s Fiduciary Overpayment Recovery Specialist (FOR) and Fiduciary Overpayment Recovery Contractor (FORC) programs click here.