| 3 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer direct the Association to identify all claims where the V1 allowance was incorrectly passed to FEPDirect, determine any FEHBP overcharges, and return those overcharges unless it can demonstrate that it made a prompt and diligent effort to recover them as per contract CS 1039.
|
| 16 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer work with the Association to implement modifications to EOB messaging in situations where member liability changes because of a claim adjustment to ensure that members are clearly notified of the changes in their liability.
|
| 2 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer direct the Association to review all 4,805 claims identified by our review as potential overcharges and to return all amounts determined to be overpaid by the FEHBP unless it can demonstrate that it made a prompt and diligent effort to recover the overpayments as per contract CS 1039. Additionally, we recommend that the contracting officer direct the Association to submit periodic reports to it on the progress of the review and recovery efforts.
|
| 4 |
No |
$23,173 |
$0 |
|
|
We recommend that the contracting officer disallow $83,565 in overcharges and direct the Association to return the funds to the FEHBP. To date, $60,392 has been recovered and $23,173 remains due to the FEHBP.
|
| 7 |
No |
$0 |
$0 |
|
|
We recommend the contracting officer direct the Association to require the Plan to provide thorough retraining to its processors on the proper procedures of recognizing and processing surprise billing claims.
|
| 11 |
No |
$4,035 |
$0 |
|
|
We recommend that the contracting officer disallow $4,035 in overcharges and direct the Association to return the funds to the FEHBP for payments of non-covered benefits.
|
| 5 |
No |
$382 |
$0 |
|
|
We recommend that the contracting officer allow $1,110 in undercharges to the FEHBP. To date, $728 in additional payments have been made and $382 remains due to providers.
|
| 6 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer ensure that the Association completes and implements the system enhancement to recognize all claim lines with the claim level surprise billing code edit.
|
| 10 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer direct the Association to require the Plan to implement controls to prevent processors from overriding edit codes requiring a completed medical review and to verify when this corrective action has been completed.
|
| 8 |
No |
$0 |
$0 |
|
|
We recommend the contracting officer direct the Association to update its Benefit Policy Manual instructions to plans to require them to use the official guidance in the FAM Chapter 19a to determine eligibility for surprise billing protections and not the member portal.
|
| 9 |
No |
$7,199 |
$0 |
|
|
We recommend that the contracting officer disallow $22,317 in overcharges and direct the Association to return the funds to the FEHBP. To date, the Plan has recovered $15,118, and $7,199 remains due to the FEHBP.
|
| 13 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer direct the Association to identify all non-covered procedure codes that do not contain the proper business rule configurations for both facility and professional claims and to make those changes to its system.
|
| 14 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer direct the Association to implement policies and procedures to update FEPDirect with all required business rules and configuration updates needed whenever changes are made to the FAM Exhibit 2, to ensure that non-covered benefits are not charged to the FEHBP.
|
| 15 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer direct the Association to ensure that the Plan institutes policies and procedures to safeguard and have ready at hand all documentation related to provider contracts that support both the contract and pricing arrangements between it and the provider.
|
