Medicare Anti-fraud Recovered $19 Billion, How Much for Private Self-Insured Plans? Fiduciary Overpayment Recovery Programs Announced from

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On February 11, 2013, HHS and DOJ announced record-breaking anti-fraud recoveries in $4.2 billion for 2012, and $14.9 billion over past four years. announced its 2013 Fiduciary Overpayment Recovery Programs for private self-insured health plans.

The question was very simple, how much did your self-insured plan get back from your TPA’s with possibly more than $19 billion anti-fraud and overpayment recovery in the private sectors?”

On February 11, 2013, HHS and DOJ announced record-breaking anti-fraud recoveries in $4.2 billion for 2012, and $14.9 billion over past four years. Additionally, CMS recovered $3.16 billion in separate non-fraud overpayment over past three years. announced its 2013 Fiduciary Overpayment Recovery (FOR) programs for private self-insured health plans, as private health insurance funds approximately 33% (Medicare 21%) of the $2.7 trillion in national healthcare expenditure, and approximately 82.1% of large health plans (>500) are self-insured.

“If all Medicare contractors had recovered $19 billion in anti-fraud and overpayment recoupment, and failed or refused to return $19 billion to Medicare and Medicaid fund, would any private self-insured plan sponsor see anything terribly wrong?” says Dr. Jin Zhou, president of, a national expert in ERISA and PPACA compliance, and a well-recognized expert in provider overpayment appeals and ERISA provider class action.

“The question is very simple: with possibly more than $19 billion in anti-fraud and overpayment recovery in the private sector, how much has your self-insured plan received from your TPA’s?” says Dr. Joe (Zhou).’s FOR programs offer both a Fiduciary Overpayment Recovery (FOR) Specialists training program for private self-insured plans and a Fiduciary Overpayment Recovery Contractor program. The groundbreaking FOR programs are unique and unlike any other traditional health plan overpayment auditing programs, which typically audit whether a TPA overpaid a provider or was overpaid for administrative fees by a plan. Fiduciary Overpayment Recovery (FOR) programs are designed to recover the alleged overpayment, regardless of fraud allegations, that have been completely recovered by the TPA’s for whatever reasons but have not been restored or refunded to the ERISA plan assets, as required under ERISA statutes and fiduciary responsibilities.

The most recent federal anti-fraud investigations, indictment, settlements or court orders are finalized with provider payments to both Medicare and Medicaid as well as private health plans. Most private health plan TPA’s overpayment recoupment practices are not as transparent or public as the Medicare or Medicaid programs, with automatic and silent recoupment from both previous patients and new patients.

It is estimated by that the private sector may have recovered more than $19 billion over past three or four years due to the alleged anti-fraud settlement inclusion with sweeping federal and state antifraud enforcement, nontransparent automatic recoupment from the previous patients and silent offsetting or withholding from new patients from other health plans. The Institute of Medicine claims that “about 30 percent of health spending in 2009 -- roughly $750 billion -- was wasted on unnecessary services, excessive administrative costs, fraud, and other problems”. FOR programs were instrumentally designed with the following OIG overpayment audit report for governmental programs:

OIG of U. S. Office of Personnel Management: “Audit of Bluecross Blue Shield Association Washington, DC and Chicago, Illinois”, March 6, 2012,

“The Association’s FEP Special Investigations Unit (SIU) is not in compliance with Contract CS 1039 and the FEHBP Carrier Letters issued by the Office of Personnel Management (OPM) related to F&A Programs and notifying OPM’s Office of the Inspector General of F&A cases in the FEHBP.”

HHS OIG Report: “Delaware Did Not Comply With Federal Requirements To Report All Medicaid Overpayment Collections”, 06/22/2012

“We found that Delaware did not comply with Federal requirements to report all Medicaid overpayment collections. Of the $16.29 million Medicaid overpayments collected, the State failed to report $16.27 million ($10 million Federal share). State officials said that they believed the overpayments had been netted out of reported Medicaid expenditures but did not provide support for such an adjustment.”

DOL Fiduciary Compliance Guidance: “Meeting Your Fiduciary Responsibilities:

“With these fiduciary responsibilities, there is also potential liability. Fiduciaries who do not follow the basic standards of conduct may be personally liable to restore any losses to the plan, or to restore any profits made through improper use of the plan’s assets resulting from their actions.”

“A plan administrator or fiduciary could be personally liable for huge plan assets losses if any TPA overpayment recovery, which could reach up to 30% of the plan annual healthcare expenses, is not refunded to the self-insured plan in a timely fashion,” said Mr. Mark Flores, vice-president and co-founder of AVYM Corporation and certified PPACA and ERISA claims specialist.

To find out more about Fiduciary Overpayment Recovery Programs from

Located in a Chicago suburb in Illinois, for over 12 years, is the only ERISA & PPACA consulting, publishing and website resource for healthcare providers in the country. offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.

For any questions, please contact Dr. Jin Zhou, president of, at 630-808-7237.

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