Audxguard

This week, the House Committee on Oversight and Accountability held a hearing as part of a recent investigation into the role of Pharmacy Benefits Managers (PBMs) that underscores the urgent need for legislative efforts to increase transparency in the PBM market. The report's findings paint a disturbing picture of an industry prioritizing profits over patient care: 🚩 Anticompetitive behavior that reduces reimbursement rates for competitors, and manipulates drug formularies to favor higher-priced medications. 🚩 Opaque pricing and overcharging via complex pricing schemes and drug utilization programs 🚩 Formulary manipulation that favors higher-priced drugs in formularies and hinders access to lower-cost alternatives like generics and biosimilars. 🚩 Overcharging and withheld rebates from government-funded health programs while steering patients to their own pharmacies. A response given multiple times from the chief executives of some of the largest PBMs in the country to some of these inquiries about these practices has been to point to the fact that the implementation of these practices were ultimately agreed and decided upon by plan sponsors. While PBMs bear the lion's share of responsibility for resisting transparency and creating a complex system that often obscures costs and limits patient choice, plan sponsors must also exercise due diligence. The increasing scrutiny of plan sponsor fiduciary duties, exemplified by cases like J&J v Lewandowski, underscores the importance of continuously and carefully evaluating service provider agreements. In the absence of stronger legislative oversight, plan sponsors can better protect their beneficiaries and mitigate financial risks by being aware of the potential pitfalls and firmly negotiating more favorable contract terms. https://lnkd.in/g9zkpaYZ

Fraudulent Billing: A $1M Wake-Up Call   A California-based laboratory has agreed to pay $1M to settle allegations of fraudulently billing Medicare for urine drug tests.   Pacific Toxicology (PacTox) has recently admitted to separately billing for urine drug tests that were already included in a single, bundled payment for its Opioid Treatment Programs (OTPs) from 2020-2023. This is just one kind of fraudulent scheme that makes up the fraudulent billing practices that have been a major target under the False Claims Act (FCA), leading to a record number of 543 settlements and judgements in 2023 and the government recovering a whopping $2.7 billion in overpayments. Fraud is defined as any instance when someone intentionally deceives or makes misrepresentations to obtain money or property of any health care benefit program.   While this case involves Medicare, it's crucial for private employers to be aware that they could be victims of similar schemes. Private insurance typically reimburses at a much higher rate than Medicare, making private plans even more attractive targets for fraudsters.   As a fiduciary responsible for your employees' healthcare benefits, it is so crucial to demand evidence that your ASO or TPA is diligently protecting your plan from these types of scams. Or, even better, get your data and see for yourself. Otherwise, how can you confirm that this type of thing isn’t happening under your nose too?

Is your health plan ready for some spring cleaning? 🌷 Q1 is officially over and 2023 claims processing should be now complete, which means it's a great time for health plans to audit their medical claims data! 🖼 Get a Complete Picture: Plans should now have a full year's worth of data to analyze, giving a clear picture of their financial health trends. 💸 Secure 2025 Savings: By identifying areas of overspending or potential errors in 2023 claims, plans can start strategizing cost-saving measures for 2025. 💪 Build Renewal Contract Negotiation Power: Armed with data-driven insights, plans can negotiate stronger contracts with their service provider when it comes time to renew. ✅ Fiduciary Compliance & Gag Clause Attestation: A proactive audit helps ensure fiduciary compliance and provides a foundation for a truthful and accurate gag clause attestation in December 2024. Don't wait! Get in touch with Audxguard to unlock the power of your data and optimize your plan for the future. #healthcare #healthplans #claimsauditing #costcontainment #fiduciarycompliance #gagclause #Q2 #2024 #getyourdatauseyourdata

We made it! Day 12 marks the end of our Attestation Countdown! Thanks for joining us on this journey towards compliance and transparency! 🎉 Remember: compliance is a marathon, not a sprint. While the initial deadline has passed, it's crucial to remember that, just like jolly ole' Saint Nick, Gag Clause attestations will be due every 12 months. Don't let this news send you into hibernation! Audxguard is here to be your trusted guide on this ongoing compliance journey. We're here all year-round here as your long-term partner in achieving and maintaining compliance 🤜 🤛 #GagClause #FiduciaryResponsibility #AttestationCountdown #caa #erisa

As we wrap up this 12 Days of Gag Clause Attestation Countdown, Day 11 brings us face-to-face with another crucial aspect of fiduciary duty: The Mental Health Parity and Addiction Equity Act (MHPAEA). It can be the missing piece in a harmonious picture of equitable healthcare, where Mental Health and Medical/Surgical coverage stand side-by-side, a 1:1 reflection of value and access. Just like the number 11 itself, the core of MHPAEA lies in balance. Every limitation placed on Mental Health benefits – quantitative, like co-pays, and non-quantitative, like prior authorizations – must be demonstrably equivalent to those imposed on the Medical/Surgical side. As an example, if a health plan requires prior authorization (NQTL) for inpatient substance use disorders treatment then, to comply with MHPAEA, the plan would need to show: ⚖ Mirroring limitations: Prior authorization exists for similar medical treatments, like a broken arm surgery. 🟰 Equal application: The pre-approval process for both remains consistent, neither stricter nor faster for substance abuse treatment. The details? They can get intricate, a snow-covered mountain to climb. But fear not, intrepid fiduciaries! Here are 5 crucial snowshoes to guide your ascent: 6️⃣ Six categories: All health plan benefits fall into six groups: Outpatient, in-network; Outpatient, OON; Inpatient, in-network; Inpatient, OON; Emergency Services; Prescription drugs. Parity must reign supreme within each. 💸 Cost-sharing fairness: Mental Health costs shouldn't shoulder a heavier burden than those for Medical/Surgical conditions. ⏸ NQTL alignment: Prior authorizations, medical guidelines, network restrictions, and drug formularies – all must be equally balanced between the two realms. 🔑 Transparency is key: Denials require clear explanations and easily accessed criteria, allowing informed choices for patients. 🚫 Out-of-network access: Mental Health shouldn't face additional hurdles compared to other services when patients seek care outside the network. As you diligently gather data for Gag Clause compliance, don't neglect the icy slopes of MHPAEA. Remember, fulfilling your fiduciary duties under ERISA means ensuring a safe and equal path for all healthcare needs, mental and medical, hand in hand. Stay tuned for deeper dives into MHPAEA compliance in the year ahead In the meantime, request your medical claims data and confirm a MHPAEA comparative analysis is underway. That's how we build a healthcare landscape where no treatment gets left in the cold ❄

❄ These winter months are dark and cold, but for many reporting entities, the heat is on! We're hurtling towards Day 10 of our Gag Clause Attestation Countdown, with the deadline just days away. Don't let non-compliance be the icing on your end-of-year stress cake! After December 31st, every day of non-compliance can lead to a $100 (aka 10 SQUARED) per-day, per-individual penalty. That's not a stocking stuffer, that's a blizzard of financial woes! 😰 Think of it this way: a plan with 200 members could face a daily fine of $20,000 – enough to put an entire holiday budget on ice! Don't let your organization suffer like a forgotten fruitcake in the back of the pantry. 🍰 Don't let your plan be at risk! Even if you aren't ready to attest, make strides to request your medical claims data from your network or TPA and document those requests. If the DOL does come down your chimney, demonstrating proactive compliance efforts will fare better than total noncompliance. And once you have that data, USE IT! Audit your claims, manage your healthcare spending, create a fiduciary structure for your health plan so that this legislation can be the gift that keeps on giving and keeping your plan in check. Get proactive, get informed, and get compliant! ✅ #caa #gagclause #erisa #informedfiduciary #proactiveCompliance #GetYourData

We're on Day 9 of our 12 Days of Gag Clause Attestation Countdown, and today we delve into the realm of Employer Identification Numbers (EINs). While seemingly commonplace, navigating their role in the attestation process can present unique challenges, especially for TPAs, PBMs, and other providers acting on behalf of multiple entities. For those multi-entity attesters: Secure the 9-digit EIN of each entity you represent. This applies even if the plan is reporting for itself. Finding elusive EINs: Payroll or Accounting Departments: Often the custodians of this vital information. A courteous inquiry should suffice. Group Health Plan (No EIN?): Utilize the plan sponsor's EIN. Think of it as the central pillar, not just an individual branch. Still Lost?: Employ the IRS's "Check Your Amended Return Status" tool – your roadmap to EIN treasure! Remember: Leading zeros: If your EIN has fewer than 9 digits, preface it with zeros (e.g., 000000237). Universal identifier: Every reporting entity, from fintech startups to artisanal bakeries, possesses a unique and indispensable EIN. Embrace transparency with confidence: Equipped with this knowledge, those with their complete data acess can confidently navigate the attestation process and usher in the New Year with compliant clarity ✨ #GagClauseCountdown #fiduciary #healthcaretransparency

Happy Holidays everyone! While we bask in the last bits of holiday cheer, let's remember another important date: December 31st, the Gag Clause Attestation deadline! And today is Day 8 of our 12 days of Attestation Countdown! The Gag Clause attestation requires certain entities involved in group health plans to report whether they have policies restricting communication about plan options and costs. When you submit your attestation, you'll need to choose one of eight options that accurately reflects your organization's policies. So, make sure you're clear on which category applies to you Here are the 8 options you'll see on the attestation form: 1. Health insurance issuer: Entities that directly offer group health insurance plans to businesses or individuals. 2. ERISA health group plan or sponsor of ERISA plan: Entities that manage employee health plans subject to ERISA regulations. 3. Non-federal governmental plan: Entities that provide health insurance to government employees outside the federal system. 4. Church Plan: Self-funded health plans sponsored by religious organizations. 5. Third-party administrator: Entities that handle administrative tasks for group health plans on behalf of another entity. 6. Pharmacy Benefit Manager: Entities that manage prescription drug benefits for group health plans. 7. Behavioral Health Manager: Entities that manage mental health and addiction treatment benefits for group health plans. 8. Other third-party service provider: Entities that provide various services to group health plans beyond claims processing or administrative tasks. Choosing the right option is crucial for compliance and avoiding potential penalties. Don't let the holiday fun distract you from making this important decision! #compliance #gagclause #fiduciary #countdown #erisa #caa

We're halfway through our 12 Days of Gag Clause Attestation Countdown, and after building those stellar fiduciary committees (remember, teamwork makes the sleigh dream work!), it's time to dive deeper into the 7 Uniform Fiduciary Standards of Care that light your path like Rudolph's red nose. While some might echo familiar notes from the 401k realm, trust us, these standards take on a unique rhythm when applied to healthcare. So, buckle up, friends, and prepare to fuel your fiduciary engine with these essential principles: 1. Know standards, laws, and trust provisions: Master the ever-shifting terrain of fiduciary rules, laws, and trust provisions. Think of it as mapping your course by starlight, ensuring clarity and direction every step of the way. 2. Assess Risk/Return Profile of Client: Understand your participants' needs and risk tolerance. Are they thrill-seeking snowboarders or cozy fireplace dwellers? Knowing their preferences is key to designing a plan that resonates. 3. Prepare Health Plan Fiduciary Policy Statement: Develop a clear, documented fiduciary policy statement that serves as your North Star. This statement isn't just pretty parchment; it's your unwavering commitment to participant well-being, etched in ink. 4. Use "Prudent Experts" and Exercise Data and Document Due Diligence: Surround yourself with "prudent experts" who possess the know-how to navigate healthcare's labyrinthine corridors. Data is your map, documents are your compass, and these experts are your seasoned guides – choose wisely! 5. Control and Account for Health Plan Expenses: Channel your inner financial sleuth and meticulously control health plan expenses. Every penny saved translates to more smiles (and healthier wallets) for your participants. 6. Monitor the Activities of "Prudent Experts" and Service Providers: Actively monitor the activities of your "prudent experts" and service providers. Remember, trust but verify; a watchful eye ensures everyone stays on the path to participant-centric decision-making. 7. Avoid Conflicts of Interest and Prohibited Transactions: Steer clear of potential conflicts of interest and prohibited transactions like a seasoned sailor dodges treacherous reefs. Transparency and ethical conduct are your guiding lights in this sometimes murky terrain. By embracing these 7 standards, you'll transform from passive observer to proactive elf-in-chief, ensuring your health plan sleighs the competition and delivers joy (and benefits!) to your participants all year long. Stay tuned for more festive insights on navigating the post-gag-clause-prohibitions world, and share your own fiduciary wisdom in the comments below! Let's make responsible data-driven healthcare our Christmas carol this year! #AttestationCountdown #Fiduciary #uniformstandardsofcare #erisa #gagclause #datadriven

We've reached the halfway mark of our 12 Days of Attestation Countdown 🎄 , and with the jingle of compliance bells still fresh in our ears, today's focus shifts from silencing gag clauses to amplifying Health Plans' fiduciary voices. Let's envision a landscape where claims data flows freely, empowering Plans to take an active role in managing costs and ensuring the well-being of their participants. But how do we turn this cheerful vision into reality? Buckle up, friends, because we're about to unlock 6 powerful steps to supercharge your fiduciary superpowers: 1. Establish a Fiduciary Committee: Form a dedicated fiduciary committee to regularly analyze the plan's pulse, discuss challenges, and chart a course for responsible claim management. Bonus points for leveraging existing groups like 401k teams! 2. Create a meeting agenda for ongoing compliance and oversight: A clear meeting agenda is your compass for ensuring everyone shares the same roadmap and knows where they are going. 3. Meet quarterly with a workbook: These meetings are pit stops on your road to fiduciary mastery and need to be happening regularly. Use a workbook to assess financial metrics, dive into claim costs, identify trends, uncover hidden risks, and celebrate victories (like decreasing costs – hooray!). 4. Document an ethical code of conduct: Have a documented standard for claim review and processing, robust conflict of interest avoidance procedures, and even consequences for unethical behavior. 5. Evaluate audits according to fiduciary standards: Regular audits are your financial detectives, sniffing out potential issues. But for maximum impact, view them through a fiduciary lens. Assess whether the scope considers all your responsibilities, evaluate their effectiveness in identifying risks, and embrace any recommendations that strengthen your fiduciary stance. Remember, audits are an opportunity to refine your financial magic, not just tick compliance boxes. 6. Remediate risks and adverse cost trends: Identifying risks is only half the battle. To truly shine as a fiduciary hero, you need to remediate them! Develop action plans to: Mitigate identified risks, tackle adverse cost trends, and continuously improve. Embrace these steps and shed the role of the passive observer. Become an active steward of your plan's future! This is just the beginning – stay tuned for more insights! #useyourdata #fiduciary #compliance #erisa #caa #gagclause