While small, innovative entrepreneurs across the nation certainly make their contribution, the U.S. economy is still very much influenced by those giant standbys, the Big Three car manufacturers, which have been known to come up with a few innovations of their own.

That's why it might behoove health plan executives and others to pay attention to the tens of millions of dollars saved by Ford and DaimlerChrysler as a result of auditing the health claims of employees.

What the companies found was thousands of former spouses and too-old children being provided employer-sponsored health coverage.

Ford began auditing employee health care claims in 2000 and has found about 50,000 ineligible dependents.

DaimlerChrysler began auditing in 2001 and has uncovered about 20,000 ineligible benefit recipients.

The Detroit News uncovered the audits when a Ford employee complained about deductions from his paycheck.

It turns out that the worker didn't know that his children, who were no longer entitled to benefits because they had turned 19, were still receiving health care subsidized by Ford.

The Wall Street Journal picked up the story from there, reporting that audit programs often find that between 10 percent and 15 percent of employees have an ineligible dependent on a plan.

"Most people aren't trying to beat the system," Michael Watson, vice president at Budco, a company that conducts audits, tells the WSJ. "The majority just don't understand the rules."

But some of it is out-and-out fraud, as Ford's experience helps illustrate. The company announced an amnesty period to allow any employees to examine their benefit package and eliminate dependents who are no longer eligible.

This helped cut a lot of ineligible people from the list. After the amnesty period, Ford began to perform random audits.

There's no discernible method to the audits but company spokeswoman Becky Bach promised that "eventually everyone is audited."

Employees who are caught face expulsion from the health plan and sometimes a huge bill for back premium payments. Some employees face both penalties.

The Ford employee mentioned above, for instance, must pay back $10,000 over two years.

"They passed out a letter and told you when to call to get everything situated," Herb Hibbs, vice president of United Auto Workers Local 862, tells the Detroit News. "Everybody in the whole Ford system had to send in something."

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.