Self-funded Health Benefits Plan Managers:
ARE YOU relying on your 'big carrier' TPA to...
- Accurately report plan assets impacted by provider claims $$ post-payment audit recoupments/recoveries? (they don't)
- Return denied claims $$ through ongoing systemic claim rejections...that you have already paid for? (probably not)
- Confirm adherence to what can appear to be simple contractual terms regarding claims processing that can have profound and expensive implications? (probably not)
HOW would you know...
without communicating with the healthcare providers that your members know and trust?
WHY should you care?
Your TPA may be engaging in other activities that directly impact your plan members, their access to benefits, as well as what is happening to plan assets AFTER claims are paid.
Not only might this activity be costing you money, your TPA just might be capitalizing in unknown-to-you ways on their contract with you outside of agreed-upon avenues for their own financial benefit.
Your TPA probably promotes their provider audit processes and their Special Investigation Unit (SIU):
- as a benefit to you;
- a way to help prevent fraud;
- a way to save you money.
IN FACT...
Predatory activity that carriers have been weaponizing against their own participating providers and healthcare facilities for years has been a way for them to capitalize on their contracts with YOU.
Activities such as:
- Accepting payment for claims from you while withholding payment (essentially indefinitely) through denials to the billing healthcare entity;
- Monetary recovery via court settlement or negotiated directly with providers (and their legal counsel) dollar amounts based upon plan claims $$, but not reported as recovered....to anyone.
Through aggressive audit recovery and egregious denial practices, they enrich themselves using these activities as alternate streams of revenue. This applies to both public and corporate plans of all sizes.
this activity is not apPaREnt when analyzing your data.
With new data transparency laws, and enhanced oversight of plan management, 2025 is the time for...
DR. ELLEN FITZENRIDER HAS SPENT MORE THAN HALF A DECADE WORKING CLOSELY WITH:
- Healthcare attorneys working in the ERISA and False Claims Act realms
- Healthcare providers, from individual practitioners to hospital systems, to the state professional associations representing them
- Health data analysts
- Health Benefits Plan Managers, public and corporate
CURIOUS? I hope so!