Ambiguous Transactions

As any experienced fraud examiner will be happy to tell you, unambiguously distinguishing individual instances of fraud, waste and abuse, one from the other, can be challenging; that’s because transactions demonstrating characteristics of one of these issues so often share characteristics of the other(s). A spate of recent articles in the trade press confirm the public impression not only that health care costs are constantly rising but that poorly controlled health care provider reimbursement systems represent significant targets of waste and abuse, both within companies themselves and from external bad actors.

While some organizations review their health benefits programs and health administrator organizations annually, others appear to be doing relatively little in this area. Consequently, CFEs are increasingly being asked as audit team members to participate in fraud risk assessments of hearth benefits administration (HBA) programs for corporations, government entities, and nonprofit organizations. As a consequence, ACFE members are increasingly identifying practices that result in recoverable losses as well as losses that were never recovered because some among our client organizations have never effectively audited their health benefit plans.

A good place to start with this type of fraud risk assessment is for the CFE to evaluate the oversight of HBA reporting activities that could identify unidentified losses for the client organization.

Many organizations contract with third-party administrators (TPAs) to oversee their employee insurance claims process, health care provider network, care utilization review, and employee health plan membership functions. In the arena of claims processing, in today’s environment of rising costs, TPAs can make significant claim payment errors that result in financial losses to the CFE’s client organization if such errors are not promptly identified, recovered, and credited back to the plan. Claim overpayments are common in the industry; and most TPAs themselves have audit processes in place to minimize the losses to their clients. Many control assurance professionals incorrectly assume that the claim audit covers all the exposures, as the primary function of claims administration is to pay claims. This misconception can block a true understanding of the nature of the exposures and lessen the client’s sense of the necessity that systematic fraud and waste detection audits of health care claims transactions are performed, both externally and internally.

The trade press recently reported that an administrator for a U.S. federal government health benefit’s health plan changed its method of administering coordination of benefits (COB) from “pursue and pay” to “pay and pursue.” Under “pursue and pay,” the administrator determines who the primary insurance payer is before making payment. Under “pay and pursue,” the administrator pays the insurance claim and pursues a refund only if it itself is determined to be the secondary payer. In this case, the clients were billed for the payment of full benefits, even though they should have been the secondary payers. The financially strapped administrator recovered the overpayments, deposited them into a bank account, and never credited its clients. Following an audit, one of the client plans received a check for $2.3 million for its share of the refunds that were not returned to it. Is this case of apparent deception an example of fraud? Of waste? Or of abuse?

If COB savings had been routinely monitored by each of the plans, along with each client’s other cost containment activities, they would have noticed that the COB savings had fallen off and were next to nothing under “pay and pursue.” When looking at COB, CFEs and client internal auditors should review the provisions of the contract with the administrator to determine who is responsible for identifying other group coverage (OGC), the methodology for investigating OGC, time limitations for recovering overpayments, and the requirements for the reporting of savings to the client organization by the administrator. In conducting their risk assessments, client management and CFEs also should consider the controls over the organization’s oversight of monitoring COB savings and over the other cost containment activities performed by the administrator.

The COB case considered above was intentional deception, but losses also can be unintentional. To recover overpayments, the TPA can use a refund request letter to request refunds from healthcare providers (hospitals, physicians, etc.), or use the provider offset method, which deducts the overpayment from the provider’s next payment. The ACFE has reported one case in which a provider voluntarily returned an overpayment. The administrator’s policy was to return the refund check to the submitting provider with a form to complete including instructions to send the form and the check back to the administrator to initiate a provider offset on the next payment to the provider. No logs were kept of the checks received and returned to the providers. Following an audit, the client found that, because of a lack of training, personnel of its administrator had deposited the returned checks from providers into an administrative holding account. Subsequent to the investigation and administrative staff training, the client’s refund activity increased from almost nothing to more than $1 million a year. Including the monitoring and analyzing of refund activity as a component of the fraud prevention program will unfailingly provide insight into how well claim overpayments are being controlled.

When assessing for fraud risk regarding refund activity for health insurance overpayments, CFEs should pay attention to the collection methods used by the administrator, overpayment amounts and time limitations for recovery, and the use of external vendors and their shared savings on recoveries. Reporting from the administrator should be required to include an analysis of refund activity, the reasons for the refund(s), breakout between solicited and unsolicited refunds, and the balance of outstanding refunds.

Sometimes it cannot be determined whether an organization’s losses are intentional or unintentional. For example, in one review, several organizations contracted with a marketing firm specializing in a new approach to control health-care costs. The marketing firm hired an administrator to process the claims for its clients. After four months with the firm, an alert accountant at one of the organizations questioned why funding requests coming from the marketing firm were running 20 percent higher each month than they had been with the previous administrator. The organization’s finance division requested a review which revealed that the marketing firm had been billing its clients based on claims processed by the administrator, including claims not paid. The firm insisted it had not been aware that the funding requests resulted in client overbilling and agreed to refund the overbilled amounts to the organization.

Monitoring and approving the funding requests against some measure of expected costs can identify when costs should be investigated. When reviewing funding requests, assurance professionals should pay attention to the internal funding approval process, supporting detail provided by the administrator to support the funding, funding limitation controls to identify possible overfunding for follow-up investigation, bank account setup and account access, and the internal funding reconciliation process.

While losses may occur because of the administrator’s practices, losses (waste) also can go undetected because the organization does not perform adequate oversight of the practices used on its accounts. Preferred provider organization (PPO) discounts are common in managed health care plans. When organizations use PPO networks that are independent of the administrator’s contracted network, the PPO networks receive the claim first to reprice it with the negotiated rate. The PPO network generates a repricing sheet, which is sent with the original claim to the administrator for processing and payment.

In one case, no one explained the repricing sheets to the claim examiners, so they ignored them. The claims system automatically priced and loaded the administrator’s network claims with the negotiated rates into the claims system. However, because the client’s external PPO network fees were not in the claims system, the claims were paid at billed charges. The client lost an estimated $750,000 in discounts over a one-year period and was paying 34 percent of the savings to the PPO networks for savings that it never received. The client did not detect the lost discounts because it never reconciled the discounts reported by the PPO’s quarterly billings for its share of the savings to a discount savings as reported by the administrator.

While examining risks regarding discounts, CFE’s auditors should review the administrator’s or independent PPO network’s contracts regarding PPO pricing and access to pricing variation for in-network provider audits, alternative savings arrangements using external vendors for out-of-network providers, and reporting of PPO discount savings. Within their own organizations, auditors should be instructed to review the internal process of monitoring discount reporting and reconcile PPO shared savings to the administrator reporting the discounts.

There are frequent reports on fraud, abuse, and errors in government health programs issued by the U.S. Department of Health and Human Services’ Office of the Inspector General and by the U.S. Government Accountability Office; all these reports can be of use to CFEs in the conduct of our investigations. Because many of our client organization’s health plans mirror government programs, the fraud risk exposure in organizations is almost everywhere the same. Organizations have incurred tremendous losses by not systematically reviewing benefits administration and through lack of understanding of the dynamics of health plan oversight within their organizations. Developing and promoting a team response within an organization to foster understanding of the exposures in the industry is a practical role for all CFEs. This posture puts fraud examiners (as members of the fraud/abuse prevention and response team) in a position to provide management with assurance that the reporting on the millions spent on employees’ health benefits is accurate and reasonable and that associated costs are justified.

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