There are many moving parts to this issue. With respect to self insured plans any monies that go out are plan assets, and likewise any monies that come back in through overpayment recoupments are also plan assets and cannot be converted.

To clarify, there is a difference between traditional “subrogation” and the practice of overpayment recoupments. Traditional “subrogation” typically occurs between the Plan and the member, usually in the case of a third party liability. Our services do not involve traditional subrogation practices. Our services address the practice of overpayment recoupments that occurs between the TPAs/ASOs and providers (facilities). TPAs typically request money back from providers and facilities for a variety of reasons, regardless of the reason the money is recouped as an “overpayment”.

Some providers will send the money back in order to make the issue go away. The monies recouped by this method are plan assets.

Others providers refuse to send money back. In this scenario when a provider (or facility) refuses to send any money back, the TPA will typically “withhold” the payment from another patient reasoning that the money was “owed” from the previous patient’s alleged “overpayment”. There are many instances where an alleged overpaid claim is withheld from a different patient in a different plan. The monies recouped using this method are also still plan assets.

Avym Corporation (Avym) announces cutting edge, unconventional 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 the reason including allegations of fraud, that have been recouped by the TPA’s but have not been restored or refunded to the ERISA plan assets as required under ERISA statutes and fiduciary responsibilities.