PAYMENT INTEGRITY SOLUTIONS
4600Boehm has been providing health plan payment integrity solutions to some of the nation’s preeminent providers for over four decades. Our services to health plans focus on the recovery and integrity of claims identified through our proprietary data mining approach as well as self-identified claims the plan provides. Additionally, each case file is closely monitored by our team of claims analysts and payment integrity specialists. Although the majority of our claims are settled prior to the need for litigated action, in those instances when more action is required, we have an in-house staff of attorneys and litigators whose knowledge is focused on the state and federal regulations that govern lien collection in workers’ compensation cases.
HEALTH PLAN PAYMENT INTEGRITY SOLUTIONS CASE STUDY
Confidential Client: National Health Plan
In April 2016, the applicant, a water sewer plant operator and engineer, contracted a pharyngeal-cervical-brachial variant of Guillain-Barre syndrome via a sinus infection, His illness necessitated inpatient hospitalization to combat the infection. The client was billed over $2.1 million by medical providers and expended $1.2 in medical benefits for this treatment. The Panel QME concluded that it was reasonably medically probable that the applicant’s occupational exposures had been contributory to the onset of the disease. The workers’ compensation claims administrator, which had originally denied the claim, accepted the claim for the purpose of administering benefits to the applicant based on the PQME report. However, it maintained its denial of the claim via a vis the lien of the health plan.
The case provided significant challenges and issues for the client and the insured injured party, including:
- The much lower compatible OMFS value of the treatment ($549,792.04) versus the amount of benefits paid ($1,092,733.71)
- The originally denied status of the claim
- Refusal of the defendant to adjust the lien once the claim was accepted
- Disqualification of the original PQME who had found the injury industrial
- Disqualification of the original PQME
- The second PQME’s deferral of the issue of causation to an infectious disease specialist
- The consulting internal QME’s initial conclusions, which did not find the work exposure the probable source of the infection
- The parties settled the case with incomplete discovery
4600Boehm Health Plan Payment Integrity Solution
As part of our client solution for this challenging case, 4600Boehm:
- Firstly, we developed a legally viable Laches argument based on unreasonable refusal by the claims administrator to adjust the lien timely in order to preclude the defendant from utilizing the OMFS to reduce the lien at a later date.
- Implementation of a notification procedure to advise the defendant of its options. And to set a baseline from which the defendant’s non-compliance may be traced\
- Completion of unfinished discovery by 4600Boehm to bolster the claim of unreasonable denial by the defendant with regard to the lien claim
- Complete litigation of the issue, including trial and appeal (by defendant)
- Finally, we obtained an award at trial and prevailed on appeal
- Subsequently, we established a viable laches argument for full reimbursement of health plan liens in other cases when these liens are unreasonably denied or deferred
After 4600Boehm undertook its completion of discovery and provided the full complement of services to support our client, the PQME agreed with the conclusions of the infectious disease consultant. Moreover, the non-panel internal QME physician (whose initial conclusions were relied upon by the defendant to bolster its denial on the basis of causation) issued her final report following a review of the PQME report and 4600Boehm infectious disease consultant’s report. She agreed that the infection arose due to employment. Additionally, 4600Boehm litigated the right to full reimbursement of the lien for all benefits paid without reduction based on the medical-legal evidence and the unreasonable delay by the defendant with regard to the lien claim. 4600Boehm prevailed at trial and following the defendant’s appeal of the decision. As a result, 4600Boehm recovered for its client not only the full amount of benefits expended by its client but also over $100K in interest from the date of the award.