Your employee hospital bills are paid from only a summary of charges

Statistically overpayments exceed $100 Billion annually

This crucial missing link from your claims payment system is causing overpayments of hospital bills and outpatient surgical bills directly affecting your organization, employees & shareholders.

The TrueFACS accuracy verification of the itemized statement for hospital bills & outpatient surgical bills will save money, is prudent, and exemplifies what those companies which are the most effective at controlling their healthcare costs will be implementing going forward.

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Under ERISA paying an accurate bill speaks directly to an employer's fiduciary responsibilities where the company's funds are co-mingled with the plan contributions of its employee/members.

To find and correct these overcharges will result in substantial savings to both employer groups and their employee plan members. A TrueFACS independent bill review through protecting and preserving plan assets can satisfy and clearly document the satisfaction of such duties.

Who?

Corporate officers, board of directors, union trustee's, municipalities, brokers, MGU's, TPA's, ASO's, stop loss carriers, HR Directors or anyone else responsible for processing, paying, or authorizing the use of comingled funds to pay employee and/or member hospital bills and/or outpatient surgical bills.

When organizations participate in a self funded health insurance plan everyone in the payer chain has a fiduciary responsibility under ERISA or Taft Hartley to assure the bills do not contain erroneous charges.

The agenda for anyone who works for or is engaged by an organization is to create and/or pursue every efficiency that will increase the bottom line of that organization.

Almost Every Hospital Bill Contains Erroneous Charges

IN 2009 HOSPITAL BILL ERRONEOUS CHARGES EXCEEDED $100 BILLION DOLLARS

How Much Is It Costing Your Organization Annually?

Working with your TPA/ASO we will conduct a line by line accuracy analysis of the itemized statement to ELIMINATE OVERPAYMENTS. Within 8 days we will provide your TPA/ASO with the corrected bill and a detailed report defining why any charge has been removed or reduced. Your TPA/ASO will then apply the PPO discount you are paying for to an accurate bill and make payment. There are no long term contracts and if we don't find any errors we don't get paid!

Our process includes:

Proprietary heuristic software formats the data on the itemized bill enabling medical doctors & compliance specialists to identify and remove erroneous charges. Additionally the platform includes hospital Chargemaster procedure costs, as well as Federal data, and other parameters that enable us to determine fair & reasonable pricing on every item/service on the itemized bill that has been determined to be billable.

Physicians licensed to practice in and residing in the United States who will analyze every line of the itemized bill to determine if it was medically necessary or even medically feasible.

Compliance Specialists who will analyze every line of the itemized bill to determine if the procedure or item is even billable to begin with.

Legal Counsel, when challenged, will defend our findings that are so thorough and beyond reproach they have prevailed on all and received sign off from the facility.

Indemnification, by an insurance policy specially designed for our business to indemnify our clients against any loss due to our auditing. We have never been sued by any hospital nor has indemnification ever been requested by any client.

A More In Depth View of Our Process

The compliance portion of our audit is based on broad and extensive knowledge of and experience with Cost Reporting Directives, federal billing mandates, correct coding initiatives for hospitals, the Social Security Act, Code of Federal Regulations, Uniform Billing Act, CMS Manuals and the False Claims Act for the sole purpose of eliminating excessive, fraudulent, and abusive hospital charges. Each UB-04 is analyzed and scrutinized for (a) correct diagnosis coding according to ICD-9-CM coding requirements, (b) correct procedure coding according to ICD-9-CM directives, which then are compared with (c) line item charges stemming from CPT/HCPCS codes contained within the itemized statement. This area of hospital bill auditing illuminates fraudulent and duplicate charges that decimate cost containment efforts made by payers.

Our unique claims review platform is heuristic technology that mirrors the various hospital items received and reviewed in the process of itemized bill review and serves as a knowledge archive for U&C pricing, clinical and technical medical billing errors, and coding and compliance issues. As the system grows and 'learns', it implements adjustment rules dictated by industry standards or client business requirements, and ensures review process consistency. It includes a robust data center, workflow automation, and a sophisticated client portal system that allows the Company to meet unique customer needs and requirements, respond quickly to problems, and continuously improve the intelligence and efficiency of the audit processes. It also allows for virtually unlimited scalability and customization, in addition to increased process automation over time.

All of the physician medical bill auditors we use undergo a two week "audit" training program that includes the following: Hospital billing process, ChargeMaster and Reimbursement methods, Revenue Codes, the UB,/CMS 1500s, Federal Billing Guidelines (Compliance), Dissecting Hospital Itemized Statements, Error Codes, ICD-9-CM, CPT/HCPCS Coding Errors, Hidden Itemized billing Coding Errors, identifying hidden duplicate charges, identifying errors that comprise the Office of the Inspector General's "18 Risk Areas of Hospital Billing". The "auditors" are then tested on bills that have been previously audited and vetted before they are qualified. Every completed audit is reviewed by our Senior Coding and Compliance Staff. Subsequently, each physician reviewer continues to be coached by the most experienced medical auditors at our disposal and, until full proficiency in medical bill review is consistently demonstrated, 100% of their work goes to a Senior Medical Director for review and sign-off.

The final quality control step is an administrative review for alignment with the individual client's business requirements. At any step in the process, a claim may be returned to the previous level for rework or correction.

Balance Billing…No Problem!

Historically 86% of our audits have never been challenged by any hospital.


When they are challenged we are contracted with ERISA attorneys who defend our findings (included as part of our service) against any balance billing attempts by a hospital or facility at which time we get sign off.


Our process is so airtight and beyond reproach that our success rate is 98+% and we have an insurance policy in place to indemnify our clients should they incur any financial loss due to our findings.


We have never been sued by any hospital or facility and indemnification has never been requested or required.

Educational Executive Overview of
ERISA Duty to Audit Hospital Claims

The Employee Retirement Income Security Act, as amended ("ERISA"), covers not only pension and retirement plans but also "employee welfare benefit plans" that include any plan, fund, or program established or maintained by an employer or employee organization to provide health care/benefits via the purchase of insurance or otherwise (a "Plan"). A person or entity exercising any discretionary authority, control or responsibility with respect to the management or administration of a Plan or the disposition of Plan assets is a "fiduciary" with specific fiduciary duties under ERISA (a "Fiduciary"). These duties are among the highest in law, adherence is strictly required and the consequences of noncompliance are harsh and may include personal liability, as well as civil penalties imposed by the U.S. Department of Labor (the "DOL") and even criminal sanctions. Each company with a self-insured group health plan and the individual committee members or trustees that handle the Plan (a "Plan Sponsor") are considered Fiduciaries. In light of what is at stake if a Fiduciary breaches ERISA duties (as discussed below), Plan Sponsors should always make some level of independent medical bill auditing an integral part of their self-insured group health plan's policies and procedures.

The duty to act in conformity with plan documents requires Plan Sponsors to ensure that the administration of claims is consistent with the Plan documents and instruments. The duty of loyalty or "exclusive benefit rule" requires that Plan Sponsors ensure that expenses paid with plan assets (which include employee contributions) are reasonable and not excessive, and that a Plan Sponsor know the costs of the services that it procures and apply due diligence to minimize costs relative to the value of services obtained. The duty of prudence requires Plan Sponsors to be careful and thorough in selecting and retaining service providers, and to proactively monitor and evaluate the performance of tasks that are delegated to such providers and confirm that such performance complies with the governing plan documents and applicable law.

Plan Sponsors may hire and delegate responsibilities to a third party administrator or an insurance company acting in the capacity of administrative services only (each an "ASO"). However, even if this results in the ASO being a Fiduciary, Plan Sponsors continue to have independent fiduciary duties and are responsible for monitoring the actions and performance of the ASO. And, if both Plan Sponsors and an ASO are responsible for a breach of duties, the Plan Sponsor can be held fully liable without any right of contribution or indemnity under ERISA against the ASO.

In a frequently cited case, trustees of an ERISA plan (the "Trustees") delegated fund management duties to another fiduciary who later misappropriated plan funds (the "Delegate"), and the Trustees were held on summary judgment to have breached their own individual fiduciary duties of prudence because they: (i) had little involvement with managing the fund; (ii) did not exercise enough oversight of the Delegate; (iii) never independently investigated the handling of the fund; (iv) failed to adopt any procedure for reviewing the checks written from the fund; and (v) relied exclusively on meeting with and reviewing an accountant's audits and legal counsels advice regarding the Delegate's management of funds. Furthermore, the court held that the insurance company that had issued D&O coverage was not liable on the policy because it never would have issued the policy in the first place if the Trustees had satisfied their fiduciary duties and accurately disclosed how the fund was being managed. Obviously, the holding in this case has major implications for any Plan Sponsor that hires an ASO to process and pay group health plan claims and does not monitor and investigate how that ASO pays claims.

The above mentioned case shows clearly how the right type of medical bill auditing can help a Plan Sponsor to satisfy and document the satisfaction of its ERISA duties. However, most Plan Sponsors incorrectly believe that their ASO is properly policing the medical bills the ASO is paying for the plan because that ASO says that they "audit" claims. The reality is that what ASO's typically do is not true auditing of medical bills, but rather payment process reviewing that does not offer a Plan Sponsor any meaningful protection with regard to its fiduciary duties under ERISA. The internal review process undertaken by most ASOs (a "Process Review") generally involves the review of a very limited number of paid claims simply to determine if: (1) the claim was paid on an eligible member; (2) the claim was paid for an eligible service; (3) claim came from a credible/recognized/properly licensed and credentialed provider; (4) bill was submitted in a proper and recognizable format (e.g., UB-04 or HCFA); (5) the proper discount level under the plan agreement has been applied in paying all of the charges billed. Even if an ASO is paying claims only for eligible members and services and at the right discount rate, any prudent Plan Sponsor needs to confirm that an ASO is only paying on valid bills. But, Process Review does not address whether or not the billing is correct in the first place!

Why? ASOs perform a valuable service but are simply not equipped to provide true medical bill auditing of the itemized statement making true bill auditing by independent professionals (rather than internal Process Review by ASO) absolutely essential!

Only this type of audit will show whether payment is being made only on clean medical bills that are free from improper/impermissible charges for services or supplies that were: (i) not actually provided; (ii) not clinically appropriate or warranted, (iii) a "never event" that was only required because of the improper action or failure to act on the part a provider or facility, (iv) billed in excess of reasonable and customary pricing; (v) double billed; (vi) mislabeled due to keystroke or ministerial error; (vii) non-routine/non-billable; or (viii) otherwise not compliantly billed and/or coded.

ACP Reporting (accuracy, compliance, pricing and payment analysis) can clearly demonstrate and document that a Plan Sponsor has properly satisfied its own fiduciary duties, and its obligation to monitor and confirm that an ASO delegate is meeting its fiduciary responsibilities, by enabling the Plan Sponsor to: (i) identify and remedy overpayments and billing inconsistencies so that plan assets are only used to pay necessary and reasonable expenses, (ii) review and evaluate ASO performance to show that it is prudently retaining the ASO and ensuring that the fees paid for ASO services are appropriate, (iii) demonstrate prudent supervision and instruction of its ASO agent and the establishment of controls and safeguards against future inconsistencies, and (iv) show its efforts to act in conformity with the plan documents and to confirm that its ASO is performing its delegated duties in a manner that is consistent with its service agreement and the plan documents and instruments.

[NOTE -- In addition to ERISA, there are other laws under which a Plan Sponsor could have an obligation to audit, or would increase its likelihood of compliance by auditing the medical bills paid by its group health plan, including: Sarbanes–Oxley Act of 2002; Workers' Compensation Law; Government Contracts Law (e.g., Cost Accounting Standards/Federal Acquisition Regulation rules/False Claims Act); Medicare/Medicaid Funding Rules; Breach of Contract under Stop Loss/D&O/Fiduciary Liability Policies; Early Retiree Reinsurance Program established in the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010; and general laws of "corporate waste" and other state laws applicable to state or local health programs.]

IF YOU HAVE QUESTIONS, PLEASE DO NOT HESITATE TO CONTACT US

HOSPITAL & FACILITY LEGAL ADVISORS ARE AWARE OF TITLE 18

TITLE 18 § 1347. HEALTH CARE FRAUD

Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice—

(1) to defraud any healthcare benefit program; or

(2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both.

(3) If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.