Claims Reduction

Overpayment Recovery & Compliance Program

The Problem: “Paid Claims” are not really “Paid Claims”

Reining in healthcare costs continues to be a challenge for both public and private employer self-funded plans. Many self-funded plans contract with TPAs for assistance in claims adjudication and payment. It is commonly perceived that these medical expenditures represent a “pass-through” from the employer self-funded plans to medical providers. Unfortunately, ample legal evidence demonstrates that this is not always the case. TPAs can and do hide “undisclosed” fees within Medical Claims payments. “Undisclosed” fees may be siphoned into the TPA’s variance account through “retention reallocations” and “cross plan overpayment” offsets, among other methods. Industry wide, recovery potential market for self-funded employer groups exceeds $19 Billion.

Solution Offering: ICC’s Overpayment Recovery & Compliance Program – Identifies Recovers and Protects both public and private Self-Funded Employer Group Health Plan Assets that have been retained by TPAs but have not been restored or refunded to the originating Employer Group health plans.

Expected Results:

• Drives potential for 10% to 30% reduction on medical claim spend and effectuate more control over claims without reducing benefits or increasing member costs
• Recovers lost plan assets ($$)
• Retains/Avoids signing away plans’ data ownership and usage rights and achieves greater transparency

Service Offerings:

• Turnkey outsourced operation, with little to no burden on employer plan employees or resources
• Review and demystify relevant documents for vague or problematic terms or provisions that may be in violation of statutory mandates
• Assist employer plan in procuring key data
• Validate that claims submissions are not modified before being submitted to employer plan
• Identify & Recover plan assets ($$) that have been improperly retained by TPA
• Ongoing monitoring to mitigate future discrepancies

Initial Term:

• Flexible Terms, No Long-Term Commitment Required from Client
• No need for Client to first provide all data/documents outlined above before retaining our services, however they are recommended to maximize recovery

Program Costs: Traditional and Alternate compensation schedules available with little to no upfront costs; including contingency option for reasonable compensation upon successful plan assets recovery. Let us know if you would like to know more.