Third Party Recovery Companies

[ste]

Aetna has hired Rawlings Financial Services and their accelerated recovery division to detect and recover potential overpayments.  My client received a letter entitled “Overpayment Notice” from Rawlings.  It basically concerns the same old story about Medicare being primary, but since Medicare doesn’t recognize the specialty, the secondary (in this case, Aetna) should pay as if they are primary.  The substance within the letter seems an easy fix but responding might involve a breach of PHI.
The letter from Rawlins does have a name and phone number in the upper right hand corner but no signature.  The letterhead is that of Rawlings Financial Services instead of Aetna.  The letter states that Rawlings is “a fully compliant HIPPA business associate retained under contract by Aetna”, but do I need to do some sort of due diligence to ensure Rawlings is actually contracted with Aetna?

[PMRNC]

The letter states that Rawlings is “a fully compliant HIPPA business associate retained under contract by Aetna”, but do I need to do some sort of due diligence to ensure Rawlings is actually contracted with Aetna?

I would def check with your client's legal counsel however MY take on this is that anyone could be a BA to any Covered Entity, but you have a BA with your client as well (also a covered entity) and disclosure of PHI without proper authorization FROM the patient WOULD violate HIPAA II M H O)

If i could just make a point though.. This question would and should be answered first from your clients compliance manual, remember they are going to be mandatory for covered entities, if there is a compliance plan in place that would be the first spot you would go to and then follow protocol.  I also think rather than play guessing games too it wouldn't be bad idea to notify the patient and get a release. 

It basically concerns the same old story about Medicare being primary, but since Medicare doesn’t recognize the specialty, the secondary (in this case, Aetna) should pay as if they are primary.  The substance within the letter seems an easy fix

How old is the claim?  In order for a collection service to get involved Aetna would have had to attempt a right of recovery first can you locate that and see if it was followed up on. Was an appeal filed? this might also NOT be as cut and dry. If the plan is an ERISA based plan, the secondary has no obligation to pay what Medicare doesn't pay. Same would apply to certain Medicare carve out plans. I would try Aetna first and make them pull the microfilm if it's really old,. Bypass Rawlings all together.

[ste]

I don’t believe these answers to your questions will change your overall suggestion of contacting Aetna and bypassing Rawlings. In any event, your questions are in bold with my answers, comments, and questions directly underneath.
 
How old is the claim?

The claims are certainly not old. It’s a group of dates of services ranging from mid-January to early May of this year.

In order for a collection service to get involved Aetna would have had to attempt a right of recovery first.

This letter is an example of Aetna exercising their right to recover except they’ve hired another company to do it for them. Rawlings is a recovery organization and not a collection agency. I think there is a distinction here.
You seem to indicate that Aetna cannot or does not outsource their recovery needs. Am I interpreting you correctly?

If the plan is an ERISA based plan, the secondary has no obligation to pay what Medicare doesn't pay.

It is a blanket plan if you are asking about how the plan is funded.

[Merry]

One more thing to add..Is Aetna a supplemental or a Medigap plan? If Medigap, they will not pay what Medicare does not approve. Just thought I would throw this in which was not meant to confuse you more.