U.S. ATTORNEY’S OFFICE AND HIGHMARK, INC. ENTER INTO UNIQUE AGREEMENT TO ADDRESS INSURERS’ OBLIGATIONS UNDER THE MEDICARE SECONDARY PAYER (MSP) RULES
Agreement Calls For Highmark To Pay More Than
$2 Million
And Establish Model
“Second Payer” System
June 19, 2006 - PHILADELPHIA – United States Attorney Pat Meehan today announced that the United States and Highmark, Inc. have entered into an agreement to resolve allegations that the Pennsylvania insurance company underpaid the amounts due for care of certain Medicare beneficiaries under the employer group health plans insured or administered by the company.
Medicare is a secondary payer (MSP) of medical costs for its beneficiaries who are current employees of an employer with 20 or more employees or of an employer of 19 or fewer employees who is a member of a multiple employer plan or group ( GHP) who has at least 1 member with 20 or more employees. These MSP rules dictate that the employer or GHP, not Medicare, is responsible for primary payment of the claims.
Highmark voluntarily conducted a review to capture actual employee count data from its customer employers for purposes of determining whether Medicare should be the primary or secondary payer. Based on the results of this review, Highmark refunded $2,517,114 to Medicare.
Under today’s settlement, Highmark agrees to pay an additional amount of $2,030.840 to the government and to implement a model Medicare Secondary Payer (MSP) program. This model has been created to address how data regarding employee counts is captured and utilized. According to the settlement, for a period of three years, an independent organization will verify that Highmark has established and maintained MSP procedures consistent with the model.
“Today’s settlement not only addresses the underpayment but it also represents a significant step forward in how insurers operate with the Medicare Secondary Payer System” said Meehan.
Highmark is a private insurance company that provides health insurance to individuals covered under various group health plans. In addition, Highmark has divisions that contract with the Department of Health and Human Services ( HHS) to process Medicare claims.
Today’s settlement concludes a whistle blower suit brought by Elizabeth Dresher, a former employee of Highmark, as well as a complaint in intervention filed by the U.S. As a result of the settlement, Ms. Dresher will receive $818,631.72.
The investigation was conducted by Stan Rukowski, HHS-OIG and Denis Cooke of the U.S. Attorney’s Office. The case has been assigned to Assistant United States Attorney Margaret L. Hutchinson.
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UNITED
STATES ATTORNEY'S OFFICE EASTERN DISTRICT, PENNSYLVANIA Suite 1250, 615 Chestnut Street Philadelphia, PA 19106 |
Contact: RICH MANIERI Media Contact 215.861.8525 |
Benjamin Franklin Photo by B. Krist for the Greater Philadelphia Tourism Marketing Corporation