County Takes Initial Step in Tightening Health Benefit Rules

Clarke County is gearing up for a closer look at the number of eligible and ineligible dependents using the County’s health care benefits. While there are no present indications of health insurance abuse, experiences in neighboring counties have Clarke officials searching for ways to tighten its oversight of who is covered and who isn’t.

“Prince William, Fauquier and Loudoun County have all identified a fair amount of fraud,” Joint Administrative Services chief Tom Judge said at Monday’s JAS meeting.

The problem that Judge and the other JAS members are trying to quantify is to what extent, if any, are County employees knowingly or unknowingly carrying ineligible dependents on their individual County health care policies. While several JAS members suggested that the responsibility, as well as the cost, for determining whether unqualified dependents were being carried on health care policies should fall to the insurance provider, Judge said that the County’s policy with Anthem placed the responsibility on Clarke County.

“Anthem is looking to us to determine who should be insured or not,” Judge said.

Judge said that the County’s health care provider, Anthem Local Choice, relies on the County to determine who should be insured and who shouldn’t. The problem is that interpreting Anthem’s dependent eligibility rules is a complex undertaking and no County employee has the appropriate training to audit the existing policies.

An example of the difficulties in interpreting the Anthem Local Choice rules came up during the meeting. According to Anthem Local Choice’s guidelines for ascertaining dependent eligibility, “other children” are defined as:

 “A child for which a court has ordered the employee to assume sole permanent custody. Additionally, if the employee or spouse shares custody with the minor child who is the parent of the parent of the ‘other child,’ then the other child may be covered.”

The somewhat indecipherable definition added support for the difficulties that a non-trained policy administrator might encounter in making decisions regarding policy dependents and prompted Supervisor Michael Hobert (Berryville) to remark “The definition itself is incredibly obtuse and poorly written.”

With the County’s 335 active health care policies covering 557 members and dependents and Clarke County taxpayers covering approximately 50% of dual and family coverage premiums, the savings potential associated with removing ineligible dependents could be significant. Even so, Judge said that his guess is that most County employees are following the rules.

“I wouldn’t be surprised if there are no cases of misuse,” Judge said after the meeting. “In larger counties it can be difficult keep track of things like this. Even though it’s easier in a smaller environment you still never know for sure until you look at it in detail.”

Because the County does not have the expertise or manpower needed to perform an audit of existing health care policies, the JAS considered several options for accomplishing the review including use of a health care audit firm as well as training an in-house employee to review the policies.

Although Judge said that an outside audit was expected to cost $1200 – $2000, the JAS team is also considering the cost of training an in-house expert who could perform random policy audits on County employee policies.

While the JAS committee didn’t reach a formal decision on how best to assess the potential for health care dependent misuse, it did decide to take an initial step towards a solution. Each County employee claiming health care dependents will be provided with a letter outlining the conditions allowing dependents to be covered by County health care policies along with a statement outlining the penalties associated with making false claims.

County employees will be required to return the forms during Anthem’s open enrollment period from May 1st – June 15th.

Comments

  1. With all the technology out there today, looks like there would be a program that could keep track of dependents and such. Wait a minute……I forgot that we do not embrace technology in this county. Never mind. Go back to searching through paper documents. Just put in a new typewriter ribbon and ditto a memo for all employees.

  2. Lonnie Bishop says:

    “Although Judge said that an outside audit was expected to cost $1200 – $2000, the JAS team is also considering the cost of training an in-house expert who could perform random policy on County employee policies.”

    “…perform random policy on County employee policies.” – What does that mean?

    CDN Editor: Corrected version: Although Judge said that an outside audit was expected to cost $1200 – $2000, the JAS team is also considering the cost of training an in-house expert who could perform random policy audits on County employee policies.

  3. Why do you need to have an outside audit. Can’t each department head audit their department. If they have questions on coverage then Anthem should be able to give an answer.