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 October 2007
Large Insurers Budget for Large Take-Backs
Does your hospital budget additional revenues from underpayment recovery? What about lost revenue from insurance company take-backs or overpayment recoveries? If not, maybe you should - because health plans are certainly budgeting huge recoveries from you as a result of their overpayment audits.
Health Check has recently learned that one of the largest national health insurance plans has budgeted more than $800M in overpayment recoveries from providers during 2007. Another major payor has budgeted $500M in additional 2007 revenue from overpayment take-backs.
Most hospitals are familiar with the process of an insurance company asking to review a number of already-processed patient claims. Inevitably, the insurance company determines that they overpaid your hospital and now they want their money back.
What do you do? What can you do? Hopefully, your hospital has the resources to review the insurance company's request, because they frequently make mistakes. Health Check has helped identify error rates as high as 95%. See the story regarding Mount Carmel Health System in this newsletter for an example.
In addition to auditing the health plan's audit, a hospital should also ensure that their managed care contracts contain language limiting how far back in time payors can review. The limits should match your hospital's timely appeal time requirements in the same contracts.
If a health insurance company is making mistakes on their overpayment audit, you can be sure that they are making mistakes on their everyday claims processing. Initiate a managed care auditing program to identify and recover underpayments from your insurance companies. If you would like help, please contact us.
Health Check Launches its New Website
Health Check Incorporated is very pleased to announce the launch of its completely redesigned website.
The new site contains more information in a new navigation style. Among the new features are:
- RSS Feeds of Industry News
- Links to Articles Related to Managed Care Reimbursement Issues
- Articles and White Papers Published by Health Check
- In addition, the new site will contain a secure section for clients to log-in and review their Quarterly, Annual, and Flash Reports from Health Check.
Please let us know what you think of our new site.
Hospital Defeats Overpayment Suit from UHC
UnitedHealthcare of Ohio claimed that Mount Carmel Health System had overcharged them for services rendered to their members and demanded that Mount Carmel return the overpayments.
Mount Carmel fought back by auditing UHC's demand, and two years later they won. They were awarded $25 million plus interest and legal fees. By reviewing their contracts and the claims, the facility was able to prove to an arbitrator that they had, in fact, been underpaid, and in some cases not paid at all, for outpatient procedures.
Health Check has no association with Mount Carmel, but this is a very good example of refusing to simply write a check when a managed care plan demands an overpayment refund. By carefully reviewing the accounts in question, a hospital can often prove that not only were the accounts not overpaid- but that they were actually underpaid.
Health Check has provided "defense audit" services to clients nationwide, including participation in arbitration or expert witness testimony. If you are facing a overpayment demand, we would be happy to discuss how we might be able to help your hospital.
UHC Continues Aquisitions
UnitedHealthcare (www.unitedhealthgroup.com) has agreed to acquire the healthcare services business of Fiserv (www.fiserv.com) for a reported $775M. The transaction, if approved, is expected to close near the end of 2007 or in early 2008.
The deal includes Fiserv's prescription mail-order service, their prescription benefits administrator, as well as Fiserv Health Plan Management, their third-party administrator for self-funded health plans.
What does this mean to your hospital? If you currently have a contract with Fiserv, you will want to monitor their payments pre-acquisition. UHC is notorious for allowing any affiliated company access to their discounted reimbursement prior to any contractual ability to do so. Also, check your UHC contracts to see what plans are allowed to access their rates, and make sure that payments are at the appropriate levels. If your hospital does not have a contract with Fiserv- pay special attention to the reimbursement on any Fiserv patient because they may very likely try to take the UHC discount.
Also, pay attention to the payment of Wausau claims, as they were recently acquired by Fiserv.
If you have any questions about the impact that this, or any of the continuing managed care consolidations, may have on your facility please feel free to contact your Health Check representative.
Health Check adds New Clients
Health Check is proud to announce that we have recently added new clients in the Pacific Northwest, Texas, and Florida.
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