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Monday, May 19, 2025 5:07:43 PM

Group health faced with 16K claims

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Posted on Nov 26 2006
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Although it has a third party administrator, the NMI Retirement Fund’s group health insurance program is burdened with having to process and settle some 16,000 medical claims of its members.

Fund administrator Mark A. Aguon said these claims were received by the previous TPA, Hawaii Pacific Medical Referral, but were not taken in by Aetna Global.

“We are reconciling these claims now. It’s done by our staff. We’re doing it in-house,” said Aguon.

The Fund decided not to refer these old claims to Aetna Global, its new third party administrator, to avoid billing problems.

Aguon said that based on its experience with HPMR, it is deemed wise not to burden the new TPA with old claims.

“We learned our lesson,” said Aguon.

The Fund got into serious financial standoff with HPMR about three years ago over billings.

Aguon said this week it was caused by that fact that both parties had agreed for HPMR to handle even the old claims or those submitted from 1996 to 2001.

As a result, HPMR had to bill the Fund more than what it could afford to pay.

In fairness to HPMR, he said that the program was “already in the red” over its pending claims before HPMR took over the job.

“It was too much for HPMR to handle the job I think and it was too much for us to pay the amount they’re asking. So to avoid that problem, we gave Aetna a clean slate. It will deal itself with the claims from the day it started,” said Aguon.

He said the group health insurance program has only three staff reconciling the claims.

The team could validate up to 40 cases a day, he said.

“It will take time before these claims are reconciled,” Aguon said.

Based on the rules, the program will only pay for claims that are submitted within one year after the treatment.

It also checks whether the claims actually belongs to its members.

“If they [providers] see that you’re from Northern Marianas, they would immediately charge it to the program. Some health providers do that so we’ve got to look out for those mistakes,” said Aguon.
He said program staff also check if the medical claim is consistent with the patient’s insurance coverage.

“It’s a meticulous process,” he said.

The Fund used to pay HPMR some $500,000 a month to handle the processing and settlement of claims.

The Fund said it now pays Aetna $100,000 too $300,000 a month for the same service.

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