Fund hires in-house utilization reviewer

In compliance with the recommendations made by the Office of Public Auditor, the NMI Retirement Fund implements its utilization review program in hopes to prevent fraudulent health claims and overblown medical charges.

Health and Life Insurance Program Manager Dolores Moore disclosed yesterday that papers of the newly-hired utilization review personnel is currently being processed.

However, Ms. Moore refused to divulge the identity of the in-house review personnel pending the release of his official papers.

She said the hiring of the in-house utilization review is due to the absence of funding assistance from the Legislature to assist them take the services of an off-island review board.

The Fund earlier asked the Legislature for $1 million revolving fund to help the project take off last month. However, both houses failed to source out financial assistance to help NMIRF.

The need for the utilization review came up following multi-million medical bills forwarded by Straub Clinic and Hospital and Queen’s Medical Center in Honolulu, Hawaii.

The two hospitals claimed multi-million medical treatments accorded to GHLI subscribers armed with off-island medical referrals.

Fund Administrator Juan S. Torres earlier disclosed that in the absence of the needed funds, NMIRF will be compelled to implement its Plan B measure which is to make utilization review in-house.

By hiring an in-house utilization review, Mr. Torres hopes to have all medical bills scrutinized and inspected prior to payment. He said, the program will be costlier than the proposed off-island URB and there won’t be discounted medical rates that the Fund earlier hoped to get.

Earlier, Public Auditor Mike Sablan asked Mr. Torres to expedite the hiring of the utilization review to prevent possible recurrence of fraudulent claims similar to Megaplus International CNMI, INC. incident.

The Fund lost an estimated $313,516 on fraudulent claims and over $500,000 in supported claims due to paid padded bills of physical therapy services rendered by Megaplus to GHLI subscribers.

The audit report disclosed that the agency paid health insurance claims supported by falsified doctors’ prescription and padded health insurance claims by billing unperformed and unnecessary treatments.

The investigation was prompted by complaints in the past that Megaplus was involved in a fraudulent transactions and providing unnecessary physical therapy services to patients.

Mr. Sablan also instructed the NMIRF to adopt a stricter measure to improve its internal control over the processing and payments of health insurance claims such as requirements of supporting claim documents and proper segregation of duties.

In addition, to prevent another incident similar to this, NMIRF should implement a stricter operating procedure such as submission of original referral letters from a doctor of medicine, submission of health insurance claim forms duly signed by patients, and submission of periodic treatment and evaluation reports by physical to justify extended medical treatment.