Case Study - The Federal Employees Health
The Federal Employees Health Benefits Act
A. Background on the FEHB Program
The Federal Employees Health Benefits Act (FEHB Act) provides heath insurance benefits to civilian federal government employees through contracting with prepaid health plans, including health maintenance organizations. Since 1978, the Office of Personnel Management (OPM) has administered the FEHB Program. Under the FEHB Act, OPM is authorized to contract with qualified carriers to provide health benefits to their personnel. Through negotiations, OPM sets the amount of premiums paid to each plan on a per subscriber basis.
B. The Dispute
Plaintiffs have asserted that the United States, acting through OPM, failed to pay the total amount of premiums due under the FEHB Program for years in which they contracted with OPM. Damages arose from the difference between what OPM owed Plaintiffs and what it actually paid during the contract period. Since payments are remitted in gross amounts with no description of the subscribers covered by each payment, differences in premiums due compared to premiums paid, had been historically difficult to reconcile and correct.
At Dispute Analytics, we have worked with a prominent Washington, DC law firm to establish accurate evaluations of FEHBP premiums by individual plans. The core analysis is based on data extracted from enrollment databases maintained by the health plans. Based on the evaluation of enrollment data at the subscriber level, we have computed premiums due. The premiums due are compared to the total premiums paid to ascertain any differences.
C. The Analysis
The objective in obtaining enrollment data from health plan is to construct a complete and historical premium coverage timeline for every subscriber, spouse, and dependent that was enrolled during the period in question. Additional data validation analyses are performed to confirm the accuracy of the data taken from the health plan's enrollment database. Once the data are tested, individual premium coverage time lines are created that identify every day a given subscriber was enrolled in the FEHB Plan and what type of coverage was provided to that subscriber. The subscriber timelines are constructed to only include periods of coverage within the overall claim period. As a result a given subscriber would be updated as their coverage changed from self-only to self-and-family, terminated if they left the plan, and re-established if they rejoined the plan. This subscriber level of detail ensures that the claim can be quantified to a reasonable certainty.
Our team members have completed engagements for over 50 FEHBP plans. Our work generally includes the database analysis, documentation, computation of any claims, expert reports, and expert testimony. Whereas most of these matters have settled, our team has provided litigation services including expert testimony before the US Court of Federal Claims.