This provision can be designed one of two ways: either the employer transfers part of the premium cost associated with covering the spouse to the employee, or the employer requires the spouse to enroll in his/her own ESI before enrolling in the employer’s plan.

There are pros and cons associated with each approach. Click here to find out more.

Click here to learn more about best practices for handling late proof of eligibility submissions.

Subrogation means if a member of a state employee health plan is injured, the plan may have the right to recover all the medical expenses it paid on behalf of the member from a liable party. Many states don’t allow subrogation unless the subrogating plan is sponsored by a government entity. When Medicaid performs subrogation, the work is backed by a Medicaid statute. If state and municipal health plans want the right to subrogate, they might have to work with legislators to draft similar subrogation provisions consistent with state law and state insurance regulations.

The key to maximizing subrogation recoveries lies in the strength of the state’s subrogation statute. To ensure that their state’s statute is effective, plans should push for the following provisions to be included:

• The plan’s right to subrogate should be explicit
• The plan should have the primary right to any money that the plan or member recovers from a liable party
• Legislation should clearly state that plan members cannot interfere with the plan’s subrogation rights—including refusing to help the plan recover medical expenses and refusing to pay the plan if the member receives money from a settlement
• The plan’s subrogation lien should be automatically presumed when a member is represented by an attorney. In cases where a member does not pay the plan back for medical expenses, the plan can pursue payment from the member and the member’s attorney.

At least one state plan has recovered more than $32 million with strong statutes like this in place.

Click here for a breakdown of the standard DEVA timeline on DependentCheck.com.

Claim audits retrospectively look at claims the administrator has already paid to identify potential processing errors and the resulting overpayments. Once overpayments are identified, the plan, the auditor, and the carrier can work together to recoup the funds and make sure future payments are accurate.

Unfortunately, it’s common for Third Party Administrator (TPA) contracts or Administrative Services Only (ASO) agreements to contain provisions that limit a plan’s ability to evaluate the Administrator’s performance, and to identify and recover overpayments.

Since their dollars are at risk, self-funded plans should understand the restrictions on their right to review claims and pursue recoveries within their ASO agreements. Once plans understand their ASO agreements, they can negotiate with their Administrator to expand their auditing and recovery rights to include more frequent, ongoing reviews; larger samples; and more ability to recover. However, in order to negotiate successfully, plans should keep the following information in mind:

• Administrators are often sensitive to the word “audit,” so plans should refer to their evaluations as “reviews.”
• Legislative and policy initiatives may be needed to address these restrictions, so plans may have to work to get these initiatives in place before negotiations can begin.
• Plans must be persistent—and, in many cases, insistent—that their Administrators allow them to take a more active role in both the claim payment review and overpayment recovery processes.

With proper negotiation, Administrators will typically agree to expand performance reviews and develop modified ASO Agreements.

Find out more about follow-up and ongoing audits on DependentCheck.com.