Payer Power

Health plans process 7% of claims in error, according to the latest data available from the American Medical Association. That adds up to more than $43 billion in overpayments since 2010.  No wonder many self-insured employers are considering a medical claim audit, a process that identifies potentially recoverable overpayments. Learn which employers would (and wouldn't) benefit from a claim audit, as well as best practices from the top U.S. companies by listening to the HMS podcast, “Self-insured Employers: Do You Need a Claim Audit?”

The 2010 Affordable Care Act (ACA) required states to implement Medicaid Recovery Audit Contractor (RAC) programs for the purpose of identifying and correcting inappropriate Medicaid payments. The Centers for Medicare & Medicaid Services oversees the RAC program as a whole and provides guidance, but states have the flexibility to select their own RAC contractor, define their audit scope, and design a RAC program that meets their specific needs.  The final episode of HMS’s podcast mini-series, “Federal Audits: What States Need to Know,” discusses some of the challenges states have faced during their Medicaid RAC implementations and offers suggestions for ensuring future success.

Medicare Recovery Audit Contractors (RACs) are tasked with identifying inappropriately paid Medicare claims and returning overpayments to the Medicare trust fund. The program has achieved nearly $5 billion in corrections since its inception in 2005, and plenty of recovery opportunities still exist. However, pushback from providers and Congress, as well as new regulations, could limit Medicare RACs’ effectiveness. Find out more about the history of the Medicare RAC program, its successes, and the political challenges it faces in the second episode of HMS’s podcast mini-series, “Federal Audits: What States Need to Know.” 

The Centers for Medicare & Medicaid Services (CMS) has long relied on Zone Program Integrity Contractors (ZPICs) and Medicaid Integrity Contractors (MICs) to address inappropriate payments and ensure program integrity for Medicare and Medicaid. Now, in an effort to improve coordination and reduce abrasion, CMS is consolidating the program integrity efforts previously carried out by ZPICs, MICs, and Program Safeguard Contractors (PSCs) into one Unified Program Integrity Contractor (UPIC) program.  The first episode of HMS’s podcast mini-series, “Federal Audits: What States Need to Know,” takes a closer look at what states can expect from this new UPIC program.

Presented by Maria Perrin at the RAC Summit. December 5, 2013. In a world of competing perspectives on Medicaid and Medicare recovery audits, you might wonder if providers and contractors can ever find common ground. Yes, they can, says HMS Chief Marketing Officer Maria Perrin.  Her fast-paced presentation at the 2013  RAC Summit highlights overlooked common ground and offers recommendations for better relationships in the future -- especially through enhanced technology and better communication.

The Centers for Medicare and Medicaid Services (CMS) reduces premiums by an average of $7,200 a year for plan members who have other primary coverage. But of the CMS data that HMS has investigated, 35% to 40% is inaccurate. As a result, a Medicare Advantage plan with 50,000 members will forfeit about $3.2 million in premiums a year—for no reason. Find out how Medicare Advantage plans can keep that money on their own or with help from a vendor by listening to HMS’s podcast, “Calling All Medicare Advantage Plans: Protect Your Premiums.”

On October 1, health insurance Exchanges (also known as “Marketplaces”) went live across the nation. This key piece of President Obama’s healthcare law is expected to have broad and sweeping implications. HMS’s podcast, “Octobergeddon? What Commercial Insurers Need to Know About Exchanges,” looks at Exchanges from a commercial insurance perspective, explaining how these organizations will be affected in the short-, medium-, and long-term.

The popularity of dependent eligibility audits has skyrocketed in recent years. And for good reason. Employers across the country have discovered that they can save thousands of dollars in healthcare costs by identifying ineligible dependents enrolled in their health plans and preventing ineligible individuals from enrolling in the future. “Dependent Eligibility Audits: Latest News and Best Practices” takes an in-depth look at this cost-saving tool, revealing how company size can impact an audit and how employers can tell if an audit was effective, as well as overall best practices for conducting an audit.

The manual coordination of benefits process is no easy task. Each year, commercial insurers must conduct frustrating annual member surveys and touch claims multiple times, often at great cost and without much payoff. What if there was a better way? HMS’s podcast, “Redefining Commercial Coordination of Benefits” explores the new frontier in coordination of benefits—automation. Automated solutions not only streamline the coordination of benefits process and ease administrative burdens, but they can also help plans save 25 cents per policy holder for month. For a 100,000-member plan, that could mean an annual savings of $300,000. Listen now to discover the reasons automated coordination of benefits is coming to the commercial market and how an automated solution can help your plan save big.

Transitional Reinsurance and Patient-Centered Outcomes Research Trust Fund (PCORI) fees are among the many changes ushered in by the Affordable Care Act (ACA) that will impact employers. Starting in 2014, group health plan sponsors will be required to pay $64 in Transitional Reinsurance and PCORI fees on all covered lives. The fees are expected to increase in later years. HMS‘s podcast, “Are You Ready for Transitional Reinsurance and PCORI Fees,” sheds light on these new employer requirements. Find out more about how these fees originated, methods for calculating covered lives and total fees owed, and strategies for minimizing their financial impact.