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Self-Insured Health Plans Should Have Recovered Millions Of Dollars From Billions Of Dollars In TPA’s Overpayment Recoupment Practice  - 02-24-2011

ERISAclaim.com Announced 2011 Free Webinars And Plan Assets Recovery Programs To Assist Self-Insured Health Plans To Recover Hundreds Of Millions Of Dollars In Plan Assets From Successful TPA’s Overpayment Recovery In Billions Of Dollars, As 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.

New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

Photo of President Gerald R. Ford signing Employee Retirement Income Security Act of 1974

President Obama Signing Health Bill on 03/23/2010

President Gerald R. Ford Signing ERISA on 09/02/1974

New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & IRS, Effective On Sept. 23, 2010 for 193 Million Americans

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UNITED STATES

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(Links to DOL) ©2010, Jin Zhou, ERISAclaim.com

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Statutory Laws [PDF] [PDF]

 

 

Employee Retirement Income Security Act — ERISA

 

Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations

 

ERISAclaim.com - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans

 

ERISAclaim.com: Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals

 

ERISAclaim.com - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois

 

ERISAclaim.com:  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)

 

Free Webinar Registration for Self-insured Health Plans

 

Space is limited and only open to self-insured health plans

Webinar Title: Overpayment Recoupment Embezzlement Recovery

Reserve your free Webinar seat now at

https://www1.gotomeeting.com/register/857663256

Date: Wednesday, December 23, 2009, Time: 12:30 PM - 1:00 PM CST

https://www1.gotomeeting.com/register/177031920

Date: Wednesday, January 27, 2010, Time: 12:30 PM - 1:30 PM CST

https://www1.gotomeeting.com/register/514303152

Date: Monday, February 22, 2010,  Time: 12:30 PM - 1:00 PM CST

Free Overpayment Webinar Announced For Self-insured Health Plans To Get Immediate Relief from New $1 Trillion Overpayment Recoupment Embezzlement Market 11-23-2009, Hanover Park, IL

 

Embezzlement Recovery Services (ERS)

for  Midsized and Large ERISA Health Plans

        “Anti-fraud initiative is not complete until and unless the recouped overpayment money originated from the plan assets is finally returned to the original self-insured health plans, or the fake anti-fraud crusaders are the real fraud culprit”, said Dr. Jin Zhou, the president of ERISAclaim.com

 Why ERISAclaim.com &

Overpayment Recoupment Embezzlement Recovery?

 

*      Compliant Recovery From Potentially Probable Embezzlement Of Plan Assets From  An Estimated More Than $1 Trillion Overpayment Recoupment Market;

*      With Our Unique Industry Expertise And Know-How, To Assist Self-insured ERISA Plans In Most Complicated And Sophisticated Healthcare Claim Environment Under ERISA, Through Compliant Claim History And Overpayment Auditing, Multiple Facet Analysis Of Claims Payment History With Overpayment Demand, Cross Plan And Across Participant Silent Overpayment Recoupment, Plan Assets Disclosure And Reporting Assistance, 5500 Form Validation, And More...... To Recover As Much As Possible From Stolen, Mismanaged Or Embezzled Plan Assets;

*      Our Embezzlement Recovery Services (ERS) From Overpayment Recoupment Market Is Completely On Contingency Basis Without Any Cost To The Plan Sponsors.

 

      The ERISAclaim.com’s new Embezzlement Recovery Services (ERS)  was created in the wake of the latest launch of Department of Justice (DOL) Financial Fraud Enforcement Task Force and recent Department Of Labor (DOL) enforcement initiative to prosecute "embezzlement of plan assets", and the reports of possible new $1 trillion successful and pending recoupment of the alleged healthcare overpayment, as reported from industry news and legislative testimony. More than 55% of employer-sponsored plan participants and beneficiaries are from self-insured ERISA plans, and the most recouped money for alleged overpayment or fraud were never returned to self-insured ERISA plans that originally paid the allegedly overpaid healthcare claims as a part of $2.5 trillion U.S. health expenditure annually.

 

     As the Attorney General Eric Holder said at DOJ Financial Task Force Press Conference on November 17, 2009, that, "This task force's mission is not just to hold accountable those who helped bring about the last financial meltdown, but to prevent another meltdown from happening”.

     "It's not enough to prosecute fraud only after it's become widespread," Treasury Secretary Timothy F. Geithner said at the DOJ press conference. "We can't wait for problems to peak before we respond. We're seeking comprehensive financial reform to create a more stable, safer financial system and stepping up our enforcement strategy."

 

      Please contact Dr. Jin Zhou at ERISAclaim@aol.com or 630-808-7237 for more details.

 

ERISAclaim.com Press Release

 

FOR IMMEDIATE RELEASE:

 

Free Overpayment Webinar Announced For Self-insured Health Plans To Get Immediate Relief from New $1 Trillion Overpayment Recoupment Embezzlement Market 11-23-2009, Hanover Park, IL

 “Anti-Fraud Initiative Is Not Complete Until And Unless The Recouped Overpayment Money Originated From The Plan Assets Is Finally Returned To The Original Self-Insured Health Plans, Or The Fake Anti-Fraud Crusaders Are The Real Fraud Culprit”, Said Dr. Jin Zhou.

New Healthcare Overpayment Recoupment Embezzlement Recovery Service Announced In Wake Of Launch of New Federal Task Force To Combat Healthcare Fraud Crisis 11-19-2009, Hanover Park, IL

Will Obama's New Financial Fraud Task Force Catch The New "Trillion-Dollar Madoff" In The Widespread $1 Trillion Healthcare Overpayment Recoupment Embezzlement Crime?

ERISAclaim.com Announced The Nation's First Embezzlement Recovery Services for Large ERISA Health Plans from the $6 Trillion Healthcare Denial Management Market 10-23-2009, Hanover Park, IL

"ERISAclaim.com has gained its unique industry in-depth knowledge and expertise from working with every segment of health care industry in more than 10 years. With unique knowledge of the industry known facts, ERISAclaim.com is dedicated to helping large ERISA plans to recover millions of dollars on a complete contingency basis."

 

      "It was a beautiful Monday morning, you woke up and found your car was stolen, you called your local police department and luckily, they found your car in one day. After you thanked them for your car's speedy recovery, the Police Department kept your car because they found the car for you, unless you call FBI, you never going to get your car back. You spoke to your high school kid and your spouse, they both believe finder don't get to keep it.  you asked them which federal and state law said so, both your kid and your spouse replied: "it's just a common sense".

 

"In healthcare industry, a lot of things don't seem to make any common sense anymore". Said, Dr. Jin Zhou, the president of ERISAclaim.com.

      It was well known that there were huge numbers of healthcare overpayment claims, an estimated more than $1 trillion, for the past 5 to 6 years, and there were reportedly successful recoveries  from providers for hundreds of millions of dollars of overpaid claims originally paid by the self-funded ERISA plans in the healthcare industry. In most cases, no one  in the country, plan sponsors, finders or even government, is sure as to who should finally get to keep the recovered ERISA plan assets, because in healthcare industry, a lot of things don't seem to make any common sense anymore.

 

ERISA TPA That Is Not a Fiduciary Must Face State-Law Breach of Contract Claims by Plan Sponsor

From the November 12, 2009 EBIA Weekly

 

[W.E. Aubuchon Co. v. BeneFirst, LLC, 2009 WL 3272491 (D. Mass. 2009)]

"The employer in this case sued the former TPA of its two self-insured medical plans for claims processing errors that allegedly created millions of dollars in additional costs for the plans. Asking the court to enter judgment in its favor, the TPA argued that the employer’s ERISA fiduciary breach claims failed because the TPA was not a fiduciary and that the employer’s state-law claims for breach of contract failed because they were preempted by ERISA."

W.E. Aubuchon Co. v. Benefirst, LLC, 2007 U.S. Dist. LEXIS 44574 (D. Mass. Feb. 6, 2007).

 

 

      Federal law, 29 U.S.C. §1106, Prohibited Transactions, specifically prohibits any TPA from embezzling, converting, or stealing the plan assets through the recouped overpayment money out of the plan assets in terms of transferring to, or using by or for the benefit of a party in interest, of any assets of the plan, or dealing with the assets of the plan in his own interest or for his own account.

 

      Federal law, 29 U.S.C. §1104, Fiduciary Duties, requires every plan administrator and fiduciary to defray reasonable expenses of administering the plan and to safeguard plan assets diligently with the care, skill and prudence. The self-insured ERISA plan administrators have statutory and fiduciary duties to investigate the alleged negligence and fraud in alleged overpayment inconsistent with plan provisions, and to take immediate actions to recover from the plan’s TPAs with successful recoupment for the alleged overpayment from the plan assets. A TPA shall return the unused or recouped plan assets to the original ERISA plan within six months. 

 

      More than 60% of  employer-sponsored health plans are self-funded with combination of the employee payroll deduction and the employer contribution.  The employee healthcare benefits are the second-largest employee expenses after employee payrolls. The double-digit increase in health insurance premiums in the past decade has put many companies out of business, including General Motors, and traumatized many otherwise healthy companies, partially leading to mass U.S. job outsourcing to other countries and to U.S. economy recession. U.S. health expenditure has been steadily skyrocketing to $2.4 trillion for 2008 and $2.529 for 2009, 16-17% of GDP.

 

     Undetected overpayment in healthcare claims is one of the most significant reason for double digits premium increase, it was reported that up to 50% of U.S. health expenditure was due to health care fraud, medical inflation, unnecessary treatment or waste and self-inflicted excessive administrative costs as well as very little  reported embezzlement of plan assets.

 

      Complete recovery of overpaid overpayment claims, originally paid out from ERISA plan assets, and to restore stolen or mismanaged ERISA plan assets to those self-funded ERISA plans are the most important and most effective ways to save hundreds of millions of dollars for 60% of the employer-sponsored health care plans in America.

 

      Unfortunately, most self-funded health plans are powerless and clueless in how to claim the stolen treasure from the "TPA or ASO" Department in the past decade because of the complexity of ERISA framework and absolute monopoly of managed-care environment, or inadvertent conflict of interest in benefits broker fraud as reported and prosecuted initially in New York and subsequently nationwide several years ago.

 

      Thanks to President Obama, with forthcoming Obama health care reform and new DOL 2010 enhancement goals announced on September 14, 2009, new DOL EBSA boss, Assistant Secretary of Labor Phyllis Borzi laid out a new and vigorous plan for the Employee Benefits Security Administration (EBSA) that she now heads. It was clear that enforcement of the law and promises made by Obama in his campaign will be a driving focus. “The previous Administration focused on compliance assistance,” she noted, “but that’s only good if it is combined with strong enforcement”, as an example, Borzi identified “embezzlement of plan assets” as “the most egregious and persistent violations” of ERISA that EBSA has initiated a criminal project to prosecute, as the new DOL ERISA regulatory enforcement drastic changes from “The previous Administration focused on compliance assistance” to the “New Sheriff” prioritized vigorous and “strong enhancement” to prosecute “embezzlement of plan assets”.

 

      Congress specifically intended in enacting ERISA in 1974 to provide exclusive authority for withholding and distribution of plan assets in case of withdrawal liability, overpayment and plan terminations regardless of contracting with service providers (TPA/ASO) and participation of managed-care networks.

 

     When an ERISA plan contracted with a TPA/ASO service provider to administer the ERISA plan claims, regardless of managed care contracting and the network participation, both plan sponsor or plan administrator and claim administrator have statutorily imposed fiduciary duties to distribute plan assets exclusively for providing benefits to the plan participant and beneficiary. When an ERISA plan terminated service contract with a TPA/ASO, the assets of welfare plan must be distributed only in accordance with terms of the plan.

 

      When a TPA/ASO service provider, fiduciary or notn-fiduciary,  discovered recoverable overpayment and successfully recovered the overpayment as the plan assets, the service provider must follow strict statutory requirements and the terms of the plan to accurately disclose and report all recovered overpayments to the plan administrator in accordance with 29 USC §1103. When a TPA/ASO discovered and recovered overpayment after the expiration of the TPA/ASO service agreement, "The assets of a welfare plan which terminates shall be distributed in accordance with the terms of the plan in accordance with 29 USC §1103. The TPA/ASO service provider shall be compensated only in accordance with relevant TPA/ASO Service Agreement with the self-funded ERISA Plan, rather than automatically convert recovered or recouped plan assets into bonus compensation for correcting its own mistakes and the negligence in overpayment practice.

 

       Under any circumstances, the assets of the welfare plan, either in form of contribution or payment, made by the employee payroll deduction or employer contribution, to a plan by mistake of fact or withdrawal of liability resulting in overpayment, are always the plan assets governed under ERISA, 29 USC §1103, rather than fraudulently claimed PPO contracting income,  paid by PPO providers to PPO operators, a sophisticated scam of embezzling ERISA plan assets.

 

       Under no circumstances, the assets of the welfare plan, negligently or inadvertently erroneously overpaid to the claimants or the providers, in form of overpayment recoupment, shall be converted illegally into unauthorized TPA/ASO compensation or bonus and subsequently embezzled as PPO income or kickback for mitigating its own negligent overpayment practice or concealment of ERISA plan assets from reporting and disclosing to the Department Of Labor and Department of Treasury in the plan Annual Returns on 5500 Forms.

 

"ERISA Madoff" Could Be 10 Times Bigger

with Your Failure of Imagination (9/11) Again

 

U.S. Health-care Crisis
& ERISA Criminal Enforcement

 

Hearing, Senate Committee on Finance, 3-3-04

View Video "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
or Transcript (PDF) (KaiserNetwork.org)

 

[Ann Combs: "No, the results are not good. It’s a tragedy."]

    "In one settled case, the district court judge had to order the US Attorney’s office to open a criminal investigation, investigation based on evidence he saw in a private civil case where there was evidence of money laundering, fraud, health care fraud, wire fraud, also sorts of RICO violations, a federal judge had to order the justice department to investigate. That’s a big problem."

Mila Kofman, Georgetown University

 

      It is extremely popular for third-party service providers to the self-funded ERISA plans to erroneously overpay healthcare claims out of the plan assets, then years later to recoup such overpayment plan assets and then convert such recouped ERISA plan assets into something but the original plan assets without disclosing and reporting to the plan administrators of those self-funded ERISA plans. Any unauthorized distribution or withholding of the plan assets from an welfare plan established under ERISA without expressed authority from the plan trust in accordance with the plan instrument shall be challenged, audited, investigated and reported to DOL and DOJ for proper regulatory enforcement investigation, meanwhile plan administrators or plan fiduciaries must take immediate actions to safeguard ERISA plan assets by recouping the plan assets from the estimated $1 trillion in overpayment recoupment market. On September 14, 2009, new DOL EBSA boss, Assistant Secretary of Labor Phyllis Borzi identified “embezzlement of plan assets” as “the most egregious and persistent violations” of ERISA that EBSA has initiated a criminal project to prosecute.

 

      With unique knowledge of industry known facts, ERISAclaim.com has launched the nation's first unique embezzlement recovery service to help midsized and large ERISA plans to recover millions of dollars on a complete contingency basis, to recoup as much as possible from the recoverable but overpaid healthcare dollars to the original payers and owners who initially paid out overpaid claims by TPAs and ASOs and are now entitled to the ownership for and the possession to an estimated billions of dollars in the $6 trillion dollar healthcare denial management market.

 

      We will utilize our unique industry expertise and know-how to assist self-funded ERISA plans in most complicated and sophisticated healthcare claim environment under ERISA, through compliant claim history and overpayment recovery auditing, multiple facet analysis of claims payment history with overpayment demand, cross plan and across participant silent overpayment recoupment, plan assets disclosure and reporting assistance, 5500 Form validation, and more...... to recover as much as possible stolen or mismanaged plan assets from  an estimated more than $1 trillion overpayment recoupment market and $6 trillion health care denial management market, including all of denied the claims  either legitimately or wrongly for the past 5 to 6 years.

 

      Knowledge is power, ERISA knowledge is superpower in healthcare industry, saving or breaking employer-sponsored health care system in America.

 

        Our Embezzlement Recovery Services (ERS) for self-funded ERISA plans are completely on contingency basis without any cost to the plan sponsors, and we are dedicated to compliant assistance through sophisticated and accurate application of ERISA regulation and diligent fact-finding as well as diplomatic communications in our embezzlement recovery services.

 

      Please contact Dr. Jin Zhou at ERISAclaim@aol.com or 630-808-7237 for more details.

 

Related Links on ERISAclaim.com:

 

ERISAclaim.com: 50% Savings - Healthcare Crisis Turnaround for Employers, Insurers & TPA's

 

ERISAclaim.com - A $1.0 Trillion Nuclear Solution to U.S. Health-care Crisis & $44 Trillion Budget Deficits 

 

ERISAclaim.com - Rx for GM $5.6 Billion Health-care Crisis with 50% Savings

 

ERISAClaim.com - Overpayment & SIU in 2009, $1 Trillion Healthcare Bailout & Foreclosures

 

ERISAclaim.com - The Death of Managed Care & Health Insurance Industry UCR Fraud

 

ERISAclaim.com - U.S. "Healthcare $1 Trillion Crisis", You Are The Bailout Plan

 

ERISAclaim.com - U.S. Health-care Crisis & ERISA Criminal Enforcement

 

ERISAclaim.com: "Failure of Imagination" Again? U.S. Health-Care Disaster

 

ERISAclaim.com: DOL Final Rules - The Rule of the Game for 80% of Healthcare Claims in the U.S.

 

ERISAclaim.com: DOL New Guidance - The Rule of the Game for 80% of Healthcare Claims in the U.S.

 

ERISAclaim.com - Supreme Court Managed Care ERISA Watch

 

####################################

 

ERISAclaim.com Press Release

 

ERISAclaim.com Press Release

 

FOR IMMEDIATE RELEASE:

 

Free Overpayment Webinar Announced For Self-insured Health Plans To Get Immediate Relief from New $1 Trillion Overpayment Recoupment Embezzlement Market 11-23-2009, Hanover Park, IL

 “Anti-Fraud Initiative Is Not Complete Until And Unless The Recouped Overpayment Money Originated From The Plan Assets Is Finally Returned To The Original Self-Insured Health Plans, Or The Fake Anti-Fraud Crusaders Are The Real Fraud Culprit”, Said Dr. Jin Zhou.

New Healthcare Overpayment Recoupment Embezzlement Recovery Service Announced In Wake Of Launch of New Federal Task Force To Combat Healthcare Fraud Crisis 11-19-2009, Hanover Park, IL

Will Obama's New Financial Fraud Task Force Catch The New "Trillion-Dollar Madoff" In The Widespread $1 Trillion Healthcare Overpayment Recoupment Embezzlement Crime?

ERISAclaim.com Announced The Nation's First Embezzlement Recovery Services for Large ERISA Health Plans from the $6 Trillion Healthcare Denial Management Market 10-23-2009, Hanover Park, IL

"ERISAclaim.com has gained its unique industry in-depth knowledge and expertise from working with every segment of health care industry in more than 10 years. With unique knowledge of the industry known facts, ERISAclaim.com is dedicated to helping large ERISA plans to recover millions of dollars on a complete contingency basis."

Related Press Release links:

 

ERISAclaim.com Announced Free ERISA Webinar for Healthcare Overpayment Dispute and Claim Denials in Response to Increasing High Demand from the $6 Trillion Healthcare Denial Management Market  10-19-2009, Hanover Park, IL

 

ERISAclaim.com Announced the Expansion of Its ERISA Litigation Support For the Healthcare Claims In Response to Increasing High Demand from the $6 Trillion Healthcare Denial Management Market. 10-19-2009, Hanover Park, IL

 

ERISAclaim.com Announced 2010 ERISA Seminars for Healthcare Overpayment and Claim Denial Appeals for the $6 Trillion Healthcare Denial Management Market. 10-14-2009, Hanover Park, IL

 

ERISAclaim.com Announced the Nation's First Certification Program for the ERISA Claim Appeal Specialist for Healthcare Providers and Managed-Care Payers, 10-13-2009, Hanover Park, IL

 

 

 

Industry Overpayment News:

 

Employment-Based Health Coverage and Health Reform: Selected Legal Considerations (PDF) (U.S. Congressional Research Service)

"It is estimated that nearly 170 million individuals have employer-based health coverage. As part of a comprehensive health care reform effort, there has been support (including from the Obama Administration) in enacting comprehensive health insurance reform that retains the employer based system. This report presents selected legal considerations inherent in amending two of the primary federal laws governing employer-sponsored health care: the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code (IRC)."

Fast Facts from EBRI (Employee Benefit Research Institute)

Contact: John MacDonald, EBRI, (202) 775-6349, macdonald@ebri.org

FFE #84, May 28, 2008

 

73 million Americans Are in Self-Insured Health Plans 

“WASHINGTON—How many Americans are covered by their employers’ self-insured health plans? Is there typically a difference in insurance type by firm size?

 

The February 2008 EBRI Issue Brief estimates that in 2007 some 73 million American workers and their dependants were covered by a self-insured health plan—that is, one in which the employer assumes the financial risk for providing health care benefits to its employees, rather than buying insurance .

 

Some 45 percent of the ERISA population was in a fully insured plan in 2007, or roughly 60 million people.”

 


Blue Cross and Blue Shield Companies' Anti-Fraud Efforts Collect More Than Half a Billion Dollars in 2009... -- WASHINGTON, May 26 /PRNewswire

"Anti-fraud savings and recoveries increase 47 percent over 2008

 

"WASHINGTON, May 26 /PRNewswire-USNewswire/ -- Blue Cross and Blue Shield companies' anti-fraud investigations resulted in overall savings and recoveries of more than $510 million in 2009, according to data released today by the Blue Cross and Blue Shield Association (BCBSA). This represents a significant increase compared to 2008, and contributed to a three-year average return of $7 dollars for every $1 dollar spent on anti-fraud efforts."

Blue Cross Blue Shield of Michigan Anti-Fraud Efforts Recoup and Save More Than $277 Million Since Inception -- DETROIT, May 26 /PRNewswire/ --

"DETROIT, May 26 /PRNewswire/ -- Blue Cross Blue Shield of Michigan's health care fraud investigation unit, the oldest and most successful health plan operation of its kind in the U.S., saved or recovered nearly $277 million since it first began operation nearly 30 years ago, including $15 million in savings in 2009."

BCBSA News, June 30, 2009

Blue Cross And Blue Shield Companies' Anti-Fraud Efforts Recover $350 Million In 2008

"WASHINGTON – Blue Cross and Blue Shield companies' anti-fraud investigations resulted in overall savings and recoveries of nearly $350 million in 2008, an increase of 43 percent from 2007, according to data released today by the Blue Cross and Blue Shield Association (BCBSA) National Anti-fraud Department (NAFD).  From 2007 to 2008, the number of cases opened increased nearly 34 percent, and the closed cases increased about 43 percent."

Independence Blue Cross Recognized for Anti-Fraud Achievemens

 

Blue Cross And Blue Shield Companies' Anti-Fraud Units Recover And Save More Than $249 Million In 2007

 

Slide 8 - Cost of Healthcare Fraud

 

Slide 12 - Cost of Healthcare Fraud

 

Anti-Fraud Initiatives

"Description: Healthcare fraud is NOT a victimless crime. It increases healthcare costs for everyone. It is as dangerous as identity theft. Fraud has left many thousands of people injured. Participation in healthcare fraud is a crime."

Blue Cross And Blue Shield Companies Receive BlueWorks Awards And Recognition By Harvard Medical School Researchers For Anti-Fraud Efforts

 

 

Testimony on Health Insurance Fraud
and Retroactive Denial of Reimbursements

Presented to
HOUSE INSURANCE COMMITTEE
Public Hearing
June 10,2009

"Over the last five years, my department -the Corporate and Financial Investigations Department - has recovered more than $192.5 million in overpaid claims, and has targeted and is pursuing an additional $64.8 million for recovery. Although a significant number, the $192.5 million we have recovered represents only four tenths of one per cent of all claims we paid over this same five-year period. Applying the national estimate, that health care fraud represents 3 percent of the amount spent on health care every year; my department should have recovered $1.4 billion. Although our recovery of $192.5 million is significant, health care fraud, waste, and abuse continues to be a problem in Pennsylvania and we need the help of the State Legislature to work with us and other insurers to protect the citizens of Pennsylvania."

 

Amednews: Pennsylvania Blues plan ordered to back off from clawbacks :: Sept. 11, 2009 ... American Medical News


BUSINESS Pennsylvania Blues plan ordered to back off from clawbacks

A mediator ruled that efforts to recoup overpayments made more than 18 months earlier violated the plan's class-action settlement.

By Emily Berry, amednews staff. Posted Sept. 11, 2009.

"A mediator ruled Aug. 13 that the Philadelphia-based plan could not collect for overpayments made more than 18 months earlier because doing so would violate a class-action settlement over payment issues between physicians and the BlueCross BlueShield Assn., reached in 2007 and finalized in June this year.....

 

Independence earlier this year sent letters to physicians at 1,483 practices notifying them that the plan intended to collect overpayments made for surgical services, some of which were in excess of $100,000, said Dennis Olmstead, chief economist and vice president for practice economics and payer relations for the Pennsylvania Medical Society."

AMNews: July 6, 2009. Tennessee Medical Assn. sues collections firm

Health Research Insights has contacted physicians in several states this year trying to collect alleged overpayments.

 

For A Copy of TMA v. HRI Lawsuit, click here

AMNews: May 18, 2009. State medical societies strategize against collector

Legal action is one option against Health Research Insights.

AMNews: May 11, 2009. Company stops tapping physicians for 'overpayments'

Doctors protested self-insured Georgia-Pacific's attempt to collect refunds of suspected claims upcoding.

AMNews: April 13, 2009. Self-insured companies going after doctors to recover 'overpaid' claims

There is no clear time limit on how far back ERISA-protected companies can go to recoup money. One company is turning that into a business.

Physicians Strike Back At Employers' Collection Firms ( BNET Healthcare Blog | BNET)

"In the most recent clash, the Tennessee Medical Association has sued Health Research Insights (HRI), a Franklin, TN-based firm that has sent collection letters to physicians in Georgia, Kentucky, Tennessee and Texas. Other defendants in the suit include the Metropolitan Government of Nashville and Davidson County, TN, and Nashville’s Board of Education, which runs a self-insured plan for school employees. Blue Cross and Blue Shield of Tennessee, the plan’s administrator, is also named in the suit, although the insurer disavows any relationship with the collection firm.

 

The suit, which alleges fraud, says that HRI keeps 40 percent of whatever it collects. The TMA wants a court to enjoin HRI from making any further efforts to collect from physicians. An earlier protest by the Georgia Medical Society against HRI’s work on behalf of Georgia Pacific led to a suspension of those activities."

Recoup d'etat: Fighting recoupment efforts

By Bob Cook, amednews staff. June 20, 2005.

"Doctors are complaining that health plans are becoming more aggressive about demanding refunds after claiming that they've overpaid. Experts say physicians can become more aggressive about fighting back.

 

Physician fights over recoupments are getting more public. For example, in August, a lawsuit is scheduled to go to trial involving $15 million in recoupments Horizon Blue Cross Blue Shield of New Jersey is seeking from cardiologists in that state. The lawsuit was filed by the New Jersey chapter of the American College of Cardiology and the Medical Society of New Jersey."

New Jersey doctors sue insurer over forced payback

By Robert Kazel, amednews staff. Jan. 3/10, 2005.


Analysts say health plans are getting more aggressive in demanding repayments from physicians.

"That mistrust was shared by many cardiologists across New Jersey who received similar overpayment notices at about the same time. In all, Horizon notified about 600 cardiologists in 273 practices that they collectively owed $15 million in connection with flawed calculation of fees for catheterizations. If repayment was not made within weeks, Horizon told some groups, it would recoup the contested funds against future reimbursements."

 

NBC 10 Breaking News:

Overpayment - FBI - Class Action

"One of the Largest Fraud in U.S. History"

NBC10 Video

$412,951.93 Overpayment Recoupment

 

Blue Cross sues doctor over payments 


NARRAGANSETT, R.I. -- Just two days after a Narragansett doctor leveled strong accusations against Blue Cross & Blue Shield of Rhode Island, he learned he was being sued. Blue Cross filed a $100,000 lawsuit against Dr. Jay Korsen for damages caused by his going public with his complaints. - turnto10.com - Jun 19, 2009

 

Doctor claims Blue Cross withheld payments 


http://www.turnto10.com/jar/news/local/article/doctor_says_bcbs/14643/
A local chiropractor says he was strong armed by Blue Cross & Blue Shield of Rhode Island. The Narrangansett doctor says Blue Cross withheld money from him and he charges them with intimidation. -  turnto10.com - Jun 17, 2009

 

 

Pomerantz Files Class Action Against Blue Cross Blue Shield Association

 

Sept. 10, 2009

"Pomerantz filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants' abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers."

For a copy of the BCBSA Complaint, click here

 

 

Pomerantz Files Class Action Against Blue Cross Blue Shield Association ("BCBSA") and Related BCBSA Entities

 

Reuters, Thu Sep 10, 2009 6:11pm EDT

 

CHICAGO--(Business Wire)--

"Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants` abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers.

Pomerantz Files Class Action Against Aetna
(News from Pomerantz)

 

For a Copy of the Official Complaint, click here

 

Pomerantz Files Class Action Suit Against Aetna On Behalf of Healthcare Providers to Challenge Abusive Post-Payment Audit Practices (GlobeNewsWire, press release)

"NEWARK, N.J., July 29, 2009 (GLOBE NEWSWIRE) -- Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC, have filed a class action lawsuit against Aetna, Inc., and its various health insurance subsidiaries on behalf of a putative nationwide class of health care providers, the Association of New Jersey Chiropractors ("ANJC") and the New York Chiropractic Council ("NYCC"). The suit challenges Aetna's abusive practices in using post-payment audits, with false allegations of fraud, to pressure providers to repay substantial sums that have previously properly been paid for providing services to Aetna subscribers.

The action alleges that Aetna's post-payment audit process violates the Employee Retirement Income Security Act of 1974 ("ERISA"), in that its repayment demands are retroactive determinations that particular services are not covered under the terms of Aetna's health care plans, but without any of the appeal or other protections otherwise available under ERISA for both self-funded and fully insured health care plans offered through private employers. The complaint further alleges that both the post-payment audit process and the pre-payment claim review process employed by Aetna to strong-arm chiropractors into unfavorable settlements violate the Racketeer Influenced and Corrupt Organizations Act ("RICO"). In addition to challenging the process by which Aetna pursues and applies its audits, the complaint also challenges numerous clinical policy bulletins of Aetna, which are used to deny services retroactively without adequate basis or clinical support."

 

 

ERISA & Claim Denials

Aetna Video Shows ERISA Patients Mistreated

 

"According to the video, when faced with claims for identical medical problems, Aetna separates the claims where no damages are available - those subject to the federal Employee Retirement Income Security Act, or ERISA - from non-ERISA claims, where consumers can sue.1 2"

 

ERISA & Health Claim
What Is ERISA and How Does It Affect Patient Rights?

 

"ERISA was enacted in 1974 to protect the pension and welfare benefits that employers provide their workers. It currently covers about 2.5 million health plans and 125 million workers, retirees, and dependents."

 

Department of Labor

 
"A group health plan is an employee welfare benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement, or otherwise.

Most private sector health plans are covered by the

 Employee Retirement Income Security Act (ERISA). Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct under the fiduciary responsibilities specified in the law."

 

 

$10,600 ERISA Claim

Recent Federal Court Ruling in a Case with $10,600 medical claim, insurance Co. refused to pay, provider made numerous demand for payment in almost one year, but no appeals filed, the court dismissed the lawsuit because provider failed to exhaust administrative remedy, as required under ERISA, by filing ERISAclaim appeals.  This situation is so popular in health-care community.

 

 

 

 

Agree to terms and conditions

"Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply."

 

CIGNA - Coverage Positions/Criteria
"The terms of a participant's particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Positions are based. If these Coverage Positions are inconsistent with the terms of the member's specific benefit plan, then the terms of the member's specific benefit plan always control."

 

UnitedHealthcare Medical Policies

"By clicking "I agree," you agree to be bound by the terms and conditions expressed below, in addition to our Site Use Agreement.

UnitedHealthcare medical policies have been made available to you as a general reference resource. When reading these policies you agree that:

Our Medical Policy is not your patient's Benefit Plan.

Your patient's medical benefits are governed and determined by a benefit document, either a Certificate of Coverage or a Summary Plan Description. You should not rely on the information contained in this Web site section to determine your patient's medical benefits.
 

  1. Federal and state mandates and the patient’s benefit document take precedence over these policies.

  2. The patient’s benefit document lists the specific services that have coverage limits or exclusions.


Our Medical Policy does not address every situation and individuals should always consult their physician before making any decisions on medical care."

 

 

 

BCBSIL Adopts New Overpayment Recovery Program
Blue Review Sept.  2004 (page 5 of 8)

"To address
this issue we are introducing a new recoupment process for refunding overpayments made to contracting providers
for the PPO, BlueChoice and BlueChoice Select products. This procedure will apply to all claim overpayments requested
after October 1, 2004.....

 

If we do not hear from you by telephone or in writing, or you do not return the amount of the overpayment within 30 days from the date of the follow up letter, BCBSIL will recover the overpayment by offsetting current claims payments by the amount due to us."

 

 

REFUND RECOUPMENT LAWS IN ALL 50 STATES (pdf) (www.mtbc.com)

"A healthcare insurer can recover an amount, wrongly paid to a provider. ... the retroactive denial of reimbursement results from COB, ...

 

 

 

Statutes (United States Code) 
ERISA - Title 29, Chapter 18. 

        Selected links:

Sec. 1002.
Definitions

Sec. 1003.
Coverage

Sec. 1022.
Summary plan description

Sec. 1027.

Retention of records
Sec. 1104.
Fiduciary duties

Sec.1106.

Prohibited transactions

Sec. 1140.
Interference with protected rights

Sec. 1141.
Coercive interference

part 7
group health plan requirements

 

 

Code of Federal Regulations

Codified in Title 29 of the Code of Federal Regulations:

Regulations

        Selected links:

2520.102-3 Contents of summary plan description.
2560.503-1 

Claims procedure.

 

 

 

 

   
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