“The California Vs Multiplan and Sutter Hospitals law suit is an unsettling yet long overdue acknowledgement of the unseemly relationship between hospitals and PPO networks set up to intentionally overcharge third party payers and their clients”………………………….”The no-audit language in PPO contracts is as ridiculous as it is grossly unfair and illegal and puts all fiduciaries associated with a health plan in harms way of severe punitive penalties”……..
MyHealthGuide Source: Advanced Medical Pricing Solutions (AMPS), 6/15/2011,www.advancedpricing.com
Medical Pricing Solutions (AMPS) has added collaborative bill audit and re-pricing service for payers wishing to create a benefit structure avoiding the contradictions of PPO contracts.
By combining, Clinical Audits with Cost–to-Charge analysis and direct physician contracting, AMPS can assist claims administrators in the creation and delivery of an ERISA compliant benefit design that provides quality coverage for their members yet avoids the unreasonable and egregious PPO contracts.
“The California Vs Multiplan and Sutter Hospitals law suit is an unsettling yet long overdue acknowledgement of the unseemly relationship between hospitals and PPO networks set up to intentionally overcharge third party payers and their clients”, said Mike Dendy, AMPS CEO/President. “The no-audit language in PPO contracts is as ridiculous as it is grossly unfair and illegal and puts all fiduciaries associated with a health plan in harms way of severe punitive penalties”, continued Dendy.
“The law suit also implicates many yet to be named third party payers who are cast into the middle of providing a network discounting service to their employer groups while knowing full well that the fees being paid for provider services are often outrageous, inaccurate, and sometimes fraudulent”, finished Dendy.
Additionally, AMPS has expanded their physician managed bill reviews to include all facility based charges. Hospital bill audit services are often associated with high dollar claims only, but expanded efficiencies and lessened turn-around times have led AMPS to pursue a wider range of claim targets. “Smaller claims are often as erroneous or egregious in mark-up as their larger counterparts” added Dendy. “It is a well documented fact that hospitals often try to make up for decreased inpatient admissions with higher outpatient charges and AMPS has expanded our audit base to include claims less than $25,000 in billed charges as an additional service to our clients.”
A measurement of the scale of the medical billing problem was announced by the New York State Comptroller, Thomas DiNapoli, in December 2008 regarding medical bill overpayments. DiNapoli’s office had recently overseen an audit of the system and turned up $1.8 billion in overpayments by the state of New York.
The Federal Government launched the RAC audit program on behalf of Medicare in all 50 states in the fall of 2009. The national expansion of this program came on the tail of a test program in three states that returned over $900 million in overpaid claims (mostly from hospitals) to the Medicare Trust Fund.
“Businesses are more in-tune with healthcare cost containment measures than ever before”, said Dendy. “The expansive public debate on health insurance reform last year sensitized senior management to healthcare costs and to how their money is being managed. For too long now we have seen the private payer industry issue client monies to hospitals without a thorough investigation of what they are actually paying for. The data we have collected over the past six years shows conclusively that hospitals are overcharging for their services in a number of ways and payers and employers alike have a right and a fiduciary obligation to verify billing validity before payment is made”, finished Dendy.