(overturning the IrO’s decision), does this mean that the payment made by the plan in accordance with the IrO’s decision is an “overpayment?” have you ever tried to recover an overpayment from a provider? The provider will argue that regardless of whether the IrO is correct (and the claims are covered by the plan), or the court and plan are right (the claims are not covered by the plan), the provider provided valuable services in good faith, and is entitled to compensation. As such, absent fraud or misrepresentation, the provider hasn’t been overpaid. Instead, the participant – who should have been responsible for the claims – was unjustly enriched by the plan, and it is the participant who owes the plan compensation. good luck getting that money back! Another concern we have relates to fiduciary status. Under ERISA, [§ 3(21)(A); see also 29 C.F.R. § 2509.75-8], a plan administrator is deemed to be the fiduciary of the plan – assigned a duty to administer the plan in strict accordance with its terms and prudently manage plan assets. This duty comes with the discretionary authority to make binding claims decisions. If the plan administrator mismanages plan assets, paying claims in excess of the plan allowance, the plan participants could take action against the fiduciary for breaching their fiduciary duty. Yet, if an IRO can overturn the plan administrator’s decision, and has the “final say” regarding how claims are paid, in those instances doesn’t the IrO have discretionary authority? If so, shouldn’t the IRO be the fiduciary? We are concerned that an IrO may require a plan to make payment in an instance with the terms of the plan clearly exclude coverage. If that occurs, might not plan participants – angered by the misuse of their funds – file a claim against their fiduciary? Of course this can happen; it has happened many times. Who, then, in this instance do they file the claim against?
Can you measure the results of your wellness services?
how can we explain this? More importantly, is this indicative of the system in a permanent sense, or might these numbers change?
visit attunelife.com to learn more Attune Health Management, Inc. 3608 Preston Rd, Suite 220 Plano, Texas 75093
May 2013
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The Self-Insurer
Of that minority of claims (claims that are denied) a surprisingly low percentage of denials are then appealed. More than three-quarters of respondents reported that less than 15% of denials re subsequently appealed. This, then, is further trimming down the pool of potential claims eligible for external appeal. The survey also revealed that of those appealed claims, very few denials are reversed.
To illustrate, this means that if I process 1,000 claims, less than 100 are denied. Of those, only 15 are appealed. As for external appeals; maybe a couple claims are taken to that level.
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More than a third of the respondents reported that less than 10% of claims coming through the door are denied. Since the issue of external appeals only applies to denied claims, this already cuts down on the number of claims that may be impacted. Of the other two-thirds, almost all remaining respondents limited denials to between 10% and 20%. So, at worst, this topic applies only to 20% or less of claims processed.
last but not least, the survey went on to tell us that of those claims which were denied, appealed, and not reversed, less than 15% of that already tiny pool is subsequently externally appealed.
WE CAN!
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Our firm recently surveyed nearly 50 high ranking members of the self-funded and claims processing community. The purpose of the survey was to determine what elements of external appeal requirements had industry members most concerned, what issues they have actually dealt with since the law was passed, and whether they have any new concerns moving forward. The results were very interesting.
let’s now shift away from statistics 3/1/2013 3:36:34 PM
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