Sunday Morning Bathroom Read ( Paul Harvey “The Rest of the Story” edition):
Horizon BC/BS was recently audited by the state of New Jersey Health Plan and it was determined that the self -funded health plan of New Jersey has been paying claims in excess of billed charges. With that said, given the fiduciary obligations at issue, some additional thoughts are also critical:
A)Contractually, this is quite common with a number of carriers. I attached an example from CIGNA;
B) Who placed the stop loss? The TPA, the one that ironically administers the health plan? What were they paid?;
C) What is the difference, if any, in the level of reimbursement to the plan by the stop loss carrier and the amount the plan sponsor reimbursed the providers?;
D) In short, did the health plan significantly overpay the providers, get shorted by the stop loss carrier on applicable claims and finally was the TPA handsomely rewarded for the privilege?
The devil is always in the details.