The What.
When you make a purchase or go out for a nice meal, do you look at the receipt? Most people do. It’s always reassuring to know that you’re getting what you paid for. Yet if your employee healthcare benefits program is state sponsored or self-funded, you may not be getting the value that your company deserves. We are Cobh Associates and we’re in the business of saving your business much needed capital. We are a team of highly trained professionals who save companies just like yours substantial money on healthcare and pharmacy employee benefit programs.
We’re not here to replace your in-house staff. We’re here to augment and assist them in evaluating and controlling the ever-increasing costs of health care. We have expert staff, intimate knowledge and high-tech resources that we put to full use in each engagement. We’ve been successful, because the companies we’ve helped have been successful in recouping and renegotiating complex and difficult agreements in the most efficient and timely manner possible.
The Who.
Imagine hiring a former IRS agent to do your taxes. That person would bring the breadth of experience and knowledge to the task. Cobh Associates is comprised of consultants and former government auditors who have extensive experience in the healthcare industry – and there is absolutely no substitute for experience. The quality of our personnel is reflected in our success record. We have sought out and hired the very best in the business. We understand the importance of tapping into the brightest and most seasoned professionals and make sure we are current and precise.
The How.
Cobh Associates specializes in retrospective audits of your company’s healthcare claims. When we are tasked with auditing hospital and pharmacy claims, we use our time wisely – incorporating statistical sampling in inpatient and outpatient claims. To maximize time, we use proprietary software to do a 100% audit of pharmacy claims.
We believe so strongly in our team and our methods that we guarantee results or we do not get paid. Data mining requires more than just great custom software. It requires the skill of someone who can decipher and analyze that data. Our constant goal is to minimize your costs while maximizing the retrieval of medical claim costs and over payments.
The Power of Re-Negotiation
Negotiation is a “discussion intended to produce agreement”. When it comes to the cost of healthcare and prescription benefit plans, good negotiation fundamentally defines the cost of doing business. Cobh Associates understands the importance of information, power and time. We are experts at re-negotiating agreements. We first gather as much information about your company and your needs as possible.
We also gather the same in-depth information from your benefits’ providers. We use that information to define your cost-saving goals and enter into negotiations armed with the power of that knowledge. We bring our experience and negotiating skills to each business activity to garner the best possible arrangement for you. If we can’t obtain a positive outcome for your company, we don’t get paid.
Medical Claim Review
State-sponsored and large employer self-funded healthcare plans generally utilize a brand name insurer such as United Healthcare © for third party administration (TPA) services, for covered services to enrollees. The TPA enters into contracts with healthcare providers, including hospitals, for covered services to enrollees.
The TPA payments to healthcare providers are passed through to the state-sponsored or large employer self-funded healthcare benefit plans along with an additional administrative fee. Cobh Associates audits TPA claims.
Our Focus Includes:
• Payments for healthcare services rendered to terminated employees
• Payments for healthcare services rendered to ineligible employee dependents
• Non-covered services
• Hospital “up-coding” of services to maximize payments
• TPA adjudication of hospital claims at payment rates higher than contract terms.
Pharmacy Benefit Management Services
State-sponsored and large employer self-funded healthcare benefit plans, much like TPA services, utilize a third party, brand-name company such as Express Scripts© or United Healthcare© for pharmacy benefit management (PBM) services.
The PBM enters into contracts with pharmacies such as CVS© or Walgreens© to fill prescriptions for covered individuals with payment on a predetermined basis. The PBM generally pays the pharmacy based on a national fee schedule or average wholesale price (AWP), minus a negotiated discount percentage.
The PBM contract with the employer provides for a predetermined payment for pharmacy claim adjudication services. The employer generally pays the PBM the AWP minus a negotiated discount percentage for prescriptions that were filled for enrollees. Essentially, the PBM functions as a middle man providing drug and claims processing services.
How PBMs make money:
• The spread between what the PBM charges it’s client and what it pays the pharmacy
• Drug manufacturer rebates not passed through to healthcare benefit plans
• Errors in interpreting contract terms
•Clerical errors
Our Focus includes:
• Inappropriate fill fee charges
• Inappropriate payments for services classified as out of network
• Prescription for retail and mail order drugs in excess of contract terms.
The information that we gather during this intense audit process we use to identify unfavorable contract terms subject to renegotiation. Typically this involves a payment rate, definition of out-of-network providers, and potential expenditure caps. We are so certain of payment recovery for our clients that we guarantee it, or we take no fee.
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JOHN J. FOLEY • C.P.A.Mr. Foley has over 40 years of accounting experience. He is the former Deputy Medicaid Inspector General for Audit Services, New York State Office of the Medicaid Inspector General (OMIG). During his tenure New York State Medicaid recoveries significantly increased each year. Mr. Foley’s expertise includes auditing managed care organizations, home health agencies, skilled nursing facilities and hospitals. Mr. Foley is recognized as an expert on Medicare and Medicaid Fraud and Abuse matters. |
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MICHAEL J. WEISNERMr. Weisner has over 35 years of experience in the field of healthcare compliance, auditing and investigations. He was formerly with the Department of Health and Human Services, Office of Inspector General. Mr. Weisner specializes in the auditing of medical providers, Medicaid agencies, Pharmacy Benefit Management firms and intermediaries. He is an expert in recovery audits, data mining, legal defense support, audit related investigations and negotiated settlements. |
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ROBERT L. YEVITZMr. Yevitz has worked in the health care field for 40 years and as an Affirmative Civil Fraud Investigator in the United States Attorney’s Office for the Middle District of Pennsylvania for 20 years. Mr. Yevitz has an extensive background in supervising multiple audits and investigations at one time including false and fraudulent billing practices. He has helped recover hundreds of millions of dollars and has received awards from various federal agencies including The United States Department of Justice. |