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Filed Under:Health Insurance, Individual Health

HHS focuses on risk pool waste and fraud

The Center for Consumer Information and Insurance Oversight (CCIIO) may be giving more attention to concerns about auditing and fraud in new Pre-existing Condition Insurance Plan (PCIP) contracting materials.

Congress created the $5 billion PCIP program to give people with serious health problems a way to buy coverage. The sick people who use the program can get major medical coverage for a price comparable to the price that healthy people in their states pay. In 2012, claims averaged about $30,000 per enrollee.

Officials at CCIIO -- pronounced "Sih-Sigh-Oh" -- startled the administrators of state-run PCIP plans  in February by announcing that CCIIO was shutting down new enrollment in federally run PCIP plans immediately and in state-run plans in just two weeks.

The Associated Press reported last week that CCIIO managers have suggested that the PCIP program as a whole will run out of cash before the date when it is supposed to shut down -- Dec. 31 -- and that states will have to make up the difference between what CCIIO can pay for the program and the actual cost of the covered claims.

Now CCIIO, the arm of the Centers for Medicare & Medicaid Services (CMS) responsible for helping the U.S. Department of Health and Human Services (HHS) implement many of the provisions of the Patient Protection and Affordable Care Act (PPACA) that affect the private health insurance market, has posted a batch of updated PCIP contract documents.

The updated documents are on the CMS website under the form number CMS-10339 (2013).

The original PCIP contract documents are on the Web at at CMS-10319 (2010).

CCIIO has posted the revised documents because the documents are going through a routine paperwork review process.

The new batch includes a copy of the PCIP contract that CCIIO asks the states running their own PCIP plans to sign; the old paperwork document batch did not include a copy of the contract.

Both batches include a supporting statement that summarizes the terms of contract. 

The old supporting statement did not refer to the terms "fraud" or "patient dumping," and it referred to the term "auditor" only in an analysis of how much the staff time spent on meeting PCIP paperwork requirements might cost a state.

In the new contract document batch, officials have included sections on "fraud, waste and abuse,"  "audited financial report, " and "reports of dumping."

PCIP "contractors" must "promptly report to HHS incidences of waste, fraud, and abuse and shall cooperate with federal law enforcement authorities in cases involving waste, fraud, and abuse," according to the revised contract.

The new supporting statement says contractors must "immediately notify HHS of any claim or suit made or filed against contractor or its subcontractors regarding any matter resulting from or relating to contractor’s obligations under the contract."

In the section on patient dumping, HHS says, "Contractors must report to HHS any health plan issuer or group health plan they have identified as discouraging an individual from remaining enrolled in coverage offered by such issuer or health plan based on the individual's health status."

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Nichole Morford

Nichole Morford
Managing Editor

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