Claim Audit Firm Halts Efforts to Recoup on Medical Claims for Two Self-Funded Firms
Reaction from AMA, TMA, GMA, Self-Funded Employer• Getahn Ward, The Tennessean, 5/16/09, Tennessee HRI Article
• Emily Berry, American Medical News, 4/13/09, AMedNews Article
• Tennessee Medical Association (TMA) Legal Department 5/5/09, TMA Alert on HRI Recoupment Letters
Franklin (TN)-based Health Research Insights, has temporarily halted efforts to collect on potential overpayments of medical claims by two Nashville-area self-insured employers to doctors and other health-care providers.
Under pressure from doctors, Metro Nashville Public Schools and Cookeville (TN)-based trucking company, Averitt Express Inc. asked Health Research Insights to stop sending letters that physicians say assume wrongdoing on their part without a review of related medical records.
Theodore L. Perry, Ph.D., President & CEO, Health Research’s CEO, said he expects the issues to be resolved by early next month. “It simply reflects an effort among the affected parties to cooperate in those efforts,” he said.
Tennessee Medical Association (TMA) Pursues Legislation to Limit Auditing Process
TMA is considering its legal options to address this situation. In its TMA Alert on HRI Recoupment Letters, TMA states:
The letters shared with TMA seem to have a similar pattern:
• The physician is accused of incorrectly billing;
• Only “claims information” is relied on to make the accusation that the physician has billed incorrectly; practices have told TMA that HRI had not requested copies of documentation from the physician before making the accusation of overbilling; and
• The claims for which HRI is demanding payments are for level 4 or 5 office visit codes.
• The letters may be followed up with high pressure telephone calls.
The TMA is pursuing legislation to allow only a health plan (such as BlueCross) with which a doctor or other providers have a contract to collect overpayments.
Bill Young, BlueCross general counsel, said that the plan administrator sees no problem with a client or self-insured employer hiring an outside firm to review claims. But Young said BlueCross would like to have a role in the process.
“Like health plans, HRI identifies physicians it believes are above the norm in the number of high-level codes they submit and targets them for recoupments. Unlike health plans, however, HRI does not analyze individual medical records along with the claims,” said AMedNews.
It uses, by the company’s own description, an algorithm to determine the amount of upcoding and overpayment — then demands that the physicians produce the medical records and other paperwork to fight the claim.
HRI Collection Letter Example
AMedNews published an example of the collection letter on behalf of self-insured Georgia-Pacific sent to Joel Fine, MD, an internist from Snellville, Ga., dated Feb. 12, and excerpted here:
Dear Health Care Professional,
Georgia-Pacific maintains a self-funded employee health benefit plan for which BlueCross BlueShield serves as the third-party administrator (TPA). Georgia-Pacific contracts with Health Research Insights (HRI) to recover funds paid by the TPA as a result of claims submitted with inaccurate or incorrect coding information. In order to perform this review and recovery, HRI maintains a HIPAA-compliant Business Associate Agreement with Georgia-Pacific plan. We analyzed claims information that your office submitted to the TPA and determined that medical claims enclosed with this letter were incorrectly billed, resulting in an overpayment to you of $347.36.
Your action is required within 15 days to settle the identified billing discrepancies:
(1) To immediately settle this issue, please refund the overpayment shown above. Return the remittance slip on the bottom of this page to ensure that your account is credited properly and make your check payable to “HRI In Trust for Georgia-Pacific” and include the account number xxxxxxxxxx on the check.
(2) If you believe the claims were improperly submitted by your organization, submit all appropriate medical records, case notes, and/or other documentation sufficient to justify your billing. Fax all supporting documentation to 615-263-0196 along with a cover sheet and a copy of this letter. Submitted documentation will be reviewed by an independent certified coding vendor. You will be notified in writing as to the outcome of this review.
You must take action as outlined in items (1) or (2) above, in order to ensure compliance with the Employee Retirement Income Security Act of 1974 (ERISA). ERISA is the federal law that, among other things, governs health benefit plans in private industry. Investigation of potential ERISA violations is given to the United States Secretary of Labor pursuant to sections 504 and 506 as amended by the Comprehensive Crime Control Act of 1984 and enforced by the US Department of Labor.
In the event HRI is not contacted by you or your designee, a Complaint may be filed with the Employee Benefits Security Administration (EBSA). You may view additional information at ( www.dol.gov/ebsa ).
If you have any questions or concerns, please feel free to contact HRI at 615-916-4480.
Sincerely,
Health Research Insights
Recovery Department
Georgia-Pacific Confident in HRI Process
AMedNews reported,
“Sheila Weidman, a spokeswoman for Georgia-Pacific, a company that has hired HRI in Georgia, said the company has confidence in HRI’s methods. She said Georgia-Pacific hired HRI in 2008 to examine its past medical claims for possible overpayments in all of its locations nationally.
“Georgia-Pacific authorized HRI to send collection letters “on a pilot basis” to doctors in the Atlanta, Savannah and Brunswick areas of Georgia, where Georgia-Pacific has a combined 5,400 employees. The 1,100 letters went out beginning in January, Weidman said.
“If the pilot is successful, she said, Georgia-Pacific could ask HRI to contact physicians across the country who have cared for any of its 45,000 employees.
AMA and Georgia Medical Association Working to Halt HRI Collection Efforts
The Medical Assn. of Georgia said it has gotten HRI to stop collections efforts there until it can investigate its work, and the Tennessee Medical Assn. is contacting federal officials and companies that have hired HRI.
Battling overpayment claims from years-old visits is not a new job for MAG, said association General Counsel Donald Palmisano Jr. Limiting health plans’ attempts to bill doctors for alleged overpayments became part of class-action settlements reached with health plans over the past few years across the country.
American Medical Association President Nancy H. Nielsen, MD, PhD, said the AMA is working with state medical associations to investigate HRI’s work to fight any activities that “lack merit.”
Warnings to Physicians to Investigate
Health care attorneys and experts in ERISA law said doctors who receive the type of letter Dr. Fine received from HRI should think twice before just sending a check.
“The reality is you don’t even have to talk with these people,” said Michael F. Schaff, an attorney who specializes in health care and contracting with the firm Wilentz, Goldman & Spitzer in Woodbridge, N.J.
“Until they show they have some type of authority, they’re bluffing,” he said. “This comes out of the blue saying, ‘You owe us X amount of dollars.’ To me, that’s extortion.”
Statute of Limitations: How far back should audit review?
Issues to be resolved include how far back Health Research should review medical claims looking for potential overpayments and what role BlueCross BlueShield of Tennessee should play as claims processor and health plan administrator for Metro schools and Averitt.
“There is no clear time limit on how far back ERISA-protected companies can go to recoup money,” reported American Medical News.
Doctors and others say state law limits such reviews to 18 months, while the company believes that, under federal law, self-funded plans have significantly longer study periods for audits. Another key issue is who should be going after possible overpayments.
Then there’s the statute of limitations question. Health plans that take on risk for employers and pay claims are governed by state law, thus they are limited to collecting overpayments only for a few years back in many states — one year in Georgia, 18 months in Tennessee, two years in Indiana.
The statute of limitations for ERISA claims is much less clear-cut, said Brian S. King, a Salt Lake City-based attorney specializing in health care litigation and contracting, particularly ERISA-related cases. “I’ve read opinions on that subject where judges use words like ‘incomprehensible’ or ‘opaque,’ ” he said.
As a bottom line, attorneys and benefits experts say physicians who are contacted by HRI or a company like it should try to shift the burden of proof back to the people trying to collect, he said. “But doctors should expect a fight, if Dr. Fine’s experience is any indication.”
Dr. Fine said his wife, who helps manage his practice, tracked down the phone number of an HRI executive. Dr. Fine said he called the number and identified himself as a recipient of a collection letter. He asked, “Why are you picking on doctors? We’re the good guys.”
The response he said he got was, “It’s very legal. We have lawyers. We’re going to keep doing this, and lots of it.”
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