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Recovery Best Practices for Motor Vehicle Accident and Worker’s Compensation Liability Claims

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Recovery Best Practices for Motor Vehicle Accident and Worker s Compensation Liability Claims Educational Session August 9, 2012 Greater Florida Buccaneer Chapter – PowerPoint PPT presentation

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Title: Recovery Best Practices for Motor Vehicle Accident and Worker’s Compensation Liability Claims


1
Recovery Best Practices for Motor Vehicle
Accident and Workers Compensation Liability
Claims
  • Educational Session
  • August 9, 2012
  • Greater Florida Buccaneer Chapter

2
Todays Discussion Points
  • Action steps to take beginning at the point of
    registration on accident and motor vehicle claims
  • The impact of state and federal laws 
  • Why hospitals may not be maximizing recoveries on
    Motor Vehicle Accident and Workers Compensation
    Liability claims
  •  
  • Training opportunities for Motor Vehicle Accident
    and Workers Compensation liability claims

3
Times Have Changed
  • Insurance companies want to know the thought
    processes physicians use to reach medical
    decisions.
  • Payments for liability injuries, such as Workers
    Compensation injuries, are rarely paid without
    medical justification.
  • Clinical documentation and well-completed forms
    can assist providers in meeting complex insurance
    and state-driven requirements.

4
High Touch Claims High Cost Claims
  • Anytime a reduced payment or no payment is
    received, the cost for billing the services rises
    dramatically.
  • These extra costs reduce the profit for the
    service.
  • The basic process to correctly fill out a claim
    form and submit to any insurance company is
    fairly similar, but each payer can be very
    specific in their individual needs.

5
Lifecycle of a Liability Claim
  • Patient presents to a facility
  • The collection of data for a medical claim begins
    at this time during check-in
  • The registrar or appointment scheduler collects
    and documents insurance information
  • The most important aspects of the medical claim
    cycle occur between the time the patient arrives
    at the facility and the time the medical claim is
    generated. It can be the shortest part of the
    entire revenue lifecycle, but also the most
    important.
  • Note Many points exist in the cycle for a claim
    to get lost or go awry.

6
Lifecycle of a Medical Claim, briefly
  • The registrar is held accountable for identifying
    all possible payers (primarily insurance
    companies).
  • During the patients evaluation, the physician is
    responsible for documenting the details of the
    encounter.
  • Dramatic changes will occur from the ICD-9
    structure to ICD-10. (More on that later.)

7
Lifecycle of a Medical Claim, continued
  • Most hospitals share software systems from
    department to department and campus to campus.
  • Typically, the hospital business office is able
    to view insurance information garnered by
    up-front registration.
  • The quality and accuracy of billing information
    and clinical documentation (as it flows through
    each department) has the single greatest impact
    on the quality of the claim.

8
Best Practices
  • Overview on Claim Handling to Achieve Greater
    Performance

9
Registration Motor Vehicle Accident
  • Patient able to communicate
  • Role of patient in accident?
  • Driver
  • Passenger
  • Pedestrian
  • Bicyclist/Motorcyclist
  • Insurance company known?
  • Drivers auto insurance company name
  • Other partys auto insurance name
  • Own health insurance as secondary plan
  • Patient unable to communicate
  • Conduct patient interview retroactively
  • Where appropriate, conduct data gathering with
    family/next of kin
  • Do not default financial class to Self-Pay
  • Verify patient eligibility and benefits under
    auto and health plans

10
Registration On-the-Job Injuries
  • Patient able to communicate
  • Employer name
  • Employer address and main phone number
  • Date of Accident
  • Basic Injury, Body Part
  • Employer HR/Manager/Foreman name and number
  • Patient unable to communicate
  • If patient was brought in with coworkers or
    supervisor, gather same data
  • Employer must file accident report with insurance
    carrier and state industrial accident board
  • Conduct interview with employer retroactively
  • Do not default financial class to Self Pay
  • If insurance carrier is known when patient
    presents to facility, call insurance for service
    authorization as soon as possible

11
Treatment Documentation
  • Substantiates services
  • Charges will be understood at insurance company
  • Validates necessity of treatment
  • Speeds up bill payment when packaged together
    (bills plus charts sent)
  • Nurses notes
  • Physicians report
  • History and Physical
  • Lab reports
  • Radiology reports
  • Therapy
  • Physical
  • Behavioral
  • Speech
  • Durable Medical Equipment
  • Implant Invoices
  • Drugs administered
  • Itemization of all services rendered

12
Claim Submission Methods
  • Electronic submission (secure 837-5010 format)
  • State compliance rules in place
  • Texas
  • California
  • Minnesota
  • Illinois
  • New York
  • Payer capability (unique to each)
  • Some are set up to accept electronic submissions
  • Paper Submission
  • Red 1500s or UBs
  • Black and White forms mostly acceptable can be
    rejected quite often
  • Fax Directly to Auto or Work Comp Adjuster
  • Note Always record submission date and location
    of where the bill and records were sent. This
    includes the specific adjusters name.

13
At the Insurance Company
  • What Happens to the Bill and Records

14
Data Centers
  • Many major Property and Casualty insurers have
    standalone data centers
  • Central mailing point
  • Mail opened and categorized by type
  • All mail is scanned into their system
  • Claim numbers found if not on documents
  • Document sent electronically to each appropriate
    adjuster across the country
  • Note having claim numbers on documents before
    mailing saves an average of 21 days of processing
    at the insurance company (really!)
  • Note If no claim number was opened or found,
    claim will be rejected. Employer must file
    accident report.
  • Sometimes data centers are within the US or
    off-shored
  • It is not customary to contact data centers
    directly for claim status

15
Data Centers, continued
  • Medical bills
  • Red paper is scanned
  • Red lines are dropped out by scanners pixel
    interpretation
  • Raw data is automatically fed to bill review
    systems
  • Less errors, but still imperfect
  • Black and white bills are manually data entered
  • Slower processing time
  • Prone to more errors in data entry
  • Always double check EOBS for insurance- rep
    errors.

16
Example UB
17
Resulting EOB with errors
18
Adjudication
  • Determination
  • Adjuster Review and/or
  • Automated Rules Engine
  • Based on accident report and severity of injury,
    adjuster will set up rules that will
    automatically OK to Pay certain services,
    taking the human element out of manual
    examination
  • Usually done with lower balance, less complex
    claims
  • The role of the adjuster is threefold
  • Own claim from start to finish
  • Examine claim validity and any evidence of fraud
  • Reduce insurance loss by predicting value of
    overall claim

19
Bill Review and Pricing
  • Managed Care departments exist in the
    Property/Casualty insurance environment!
  • Line-by-line re-pricing of bills occurs using
    various methods
  • PPO contracts
  • Fee schedule
  • Usual and Customary guidelines
  • Nurse case management
  • DRG (not line-by-line analysis rather a fixed
    code)
  • Many other methodologies
  • A few words on Silent PPOs
  • When a claim is paid, an Explanation of Benefits
    (EOB) is issued with the check
  • The rationale of payment should indicate if a
    contractual agreement was used
  • Does the facility really have a contract in place
    with the PPO mentioned on the EOB?
  • Challenge the insurer if not!

20
Utilization Review
  • As many hospitals have UR departments, insurance
    companies do too.
  • Nurses and doctors are retained on staff to
    investigate medical necessity and claim validity,
    especially for high balance and complex situations
  • They examine clinical documentation against
    services listed on the bill
  • They have conversations with hospital physicians
    to question or dispute certain services and tests
  • They reduce insurance loss by disputing or
    denying coverage based on clinical knowledge

21
Reimbursement Methods Florida
  • How a Claim is Paid (or Not)

22
How Bills Are Valued
  • Work Comp Inpatient Per Diem or 75 of charges
    if stop loss exceeded for Acute Care
    Hospitals/Trauma Centers.
  • Work Comp Outpatient 75 of charges for
    emergency room services, 60 of charges for
    scheduled outpatient surgeries. Otherwise,
    specified codes paid to fee schedule, all others
    75 of charges.
  • MVA Inpatient Non emergency - 200 of CMS DRG
    methodology.
  • MVA Outpatient Non emergency - 200 of CMS APC
    methodology

23
Negligence Rules and Insurance Policies
  • No-fault state
  • Pure comparative negligence (a persons own
    percentage of negligence is uncollectible by
    him/her)
  • Coordination of Benefits rules in place
  • By county hospital liens in place
  • Escalation points available if auto payers are
    uncooperative
  • Statistics
  • MVA Injuries 195,104 (2010)
  • Fatalities 2,444 (2010)
  • Avg. crashes per day 645
  • Insurance
  • 10,000 bodily injury per person
  • 20,000 bodily injury per accident (Personal
    Injury Protection PIP)

Courtesy FL Department of Public Safety, FL Dept
of Insurance
24
Florida Workplace Injuries
  • Major employers in Florida
  • Alamo Rental
  • Anheiser-Busch
  • Carnival Cruise Lines
  • Charter One Hotels Resorts
  • Citrix Systems
  • Eckerd Drug Stores
  • Florida Power and Light
  • Publix Grocery
  • Ryder Trucks
  • Steinmart
  • Tropicana
  • US Sugar Corporation
  • Wal-Mart
  • Walt Disney
  • Wellcraft
  • 18,537,969 Floridas total population (2009)
  • 7,018,700 total employees in Florida (2010)
  • 222,600 total injuries
  • 215 total fatalities
  • 10 unemployment rate

Courtesy US Census Bureau of Labor Statistics
Floridas Largest Employers Job Bank USA
25
Florida Bill Payment Timeliness
  • The insurer has 45 days to pay or explain reason
    for non-payment of medical claims. (FL Stat
    440.20(2-b))
  • The insurer has 120 days to either pay or deny a
    disputed medical claim. (FL Stat 440.20(4))
  • Hospitals must notify insurers that they rendered
    emergency care within 24 hours of admitting an
    employee, and 3 days in non-admission cases. (FL
    Stat 440.13(3-b))

26
Types of Reimbursement National Overview
  • APCs
  • Capitation
  • Case rate
  • DRG
  • Day Differentials
  • Service Differentials
  • Fee Schedule and Timely Pay Fee Schedules
  • Flat Rate
  • Per Diem
  • Managed Care stop loss outliers
  • Case based outliers
  • Reinsurance stop loss
  • Percentage stop loss
  • At Charges
  • Sliding scale discounts
  • All methodologies operate under various
    contracts, policies, and guidelines, that all
    depend on state and federal laws

27
Breaking the Methodologies Down
  • Ambulatory Payment Classifications Based on
    PROCEDURES, not diagnoses. Services are assigned
    a group code
  • Surgical
  • Significant procedures
  • Medical
  • Ancillary
  • Note Modifiers are important to clarify multiple
    services!
  • Capitation/Percent of Revenue Reimbursement to
    the hospital on a per-member, per-month basis
    regardless of hospitalization. Percent of Revenue
    is a fixed rate of payment.
  • Case Rate Averaging after a flat rate for a
    service has been given to certain categories of
    procedures. Specialty procedures may be given a
    case rate (e.g., graft surgery). Bundled case
    rate is an all-inclusive rate for institutional
    and professional services connected with the
    procedure.
  • APCs
  • Capitation
  • Case rate

28
Breaking the Methodologies Down
  • Diagnosis-related groups A classification system
    that categorizes patients who are medically
    related, with respect to diagnosis and treatment.
    They are statistically similar in length of
    hospital stay. Its a lump-sum, fixed-fee based
    on diagnoses. Fees are made by a research team,
    which determine national averages. DRG numbers go
    from 001 to 900. Variables in DRG classification
  • Principal Diagnosis Secondary diagnosis (up to
    eight)
  • Surgical procedures (up to six)
  • Comorbidity (pre-existing conditions) and
    complications
  • Age and sex
  • Discharge status
  • Number of hospital days for a specific diagnosis
  • Day Differential First day paid at higher rate,
    cascading down each following day.
  • Service Differential Hospital receives a flat
    per-admission reimbursement for the service. A
    prorated payment can be made (e.g., 50 ICU, 50
    medical services) Services are defined in the
    contract
  • DRG
  • Day Differentials
  • Service Differentials

Courtesy Marilyn Fordney Medical Administrative
Procedures
29
Breaking the Methodologies Down
  • Fee schedule list of charges based on procedure
    codes. Fee-for-service basis.
  • Flat Rate A set amount per hospital admission
    regardless of cost of actual services
  • Per diem single charge for a day in the
    hospital, regardless of actual charges or costs
  • Case-based stop loss A mechanism of hospital and
    insurance carrier sharing loss. It is a payment
    of a percentage over a certain dollar threshold
    (e.g., 65 of excess billing over 100,000.)
  • Reinsurance stop loss The hospital buys
    insurance to protect against lost revenue and
    receives less of a cap fee. The amount they dont
    receive helps pay for the reinsurance. Example A
    case reaches 100,000. The plan may allow 80 of
    expenses in excess of that figure for the rest of
    the year.
  • Percentage stop loss A percentage paid of
    charges when a certain threshold is met.
  • Fee Schedule
  • Flat Rate
  • Per Diem
  • Managed Care stop loss outliers
  • Case based outliers
  • Reinsurance stop loss
  • Percentage stop loss

30
Workers Compensation Details
  • Analyzing the Process

31
A Very, Very Brief History
  • Workers in the late 1800s had it tough. For
    injuries and deaths, the legal processes were
    uncertain. Negligence had to be proven on the
    part of the employee.
  • In 1911, the first workers compensation laws
    were adopted by many states. The laws allowed
    injured workers to receive medical care without
    first taking employers to court.
  • All states currently have workers compensation
    laws. They vary from state to state.
  • This coverage is the most important coverage
    written to insure industrial accidents.

32
Types of Coverage
  • Two kinds
  • Federal compensation laws
  • Applies to miners, maritime workers, and
    government workers
  • State compensation laws
  • State and private business employees

33
Self-Insured Employers
  • Employers pay for medical expenses directly
    instead of insurance premiums
  • Precertification is important the self-insured
    employer is very mindful of treatment costs
  • Self-insured employers are covered by ERISA
    (Employee Retirement Income Security Act.)
  • Mandates reporting
  • Not state regulated is under federal
    jurisdiction
  • 90-105 day payment timeline. Employers may
    violate this there are no penalties for
    violation. Courteous but aggressive pursuit is a
    must.

34
The Beginnings of Workers Compensation Reform
  • By 1994, dysfunction Work Comp systems were
    costing companies more than 65 billion annually
    in many US cities.
  • Insurers began denying coverage to businesses.
  • Some businesses began relocating to states
    allowing lower premiums.
  • Widespread legal and medical corruption and abuse
    evolved throughout the system.

35
What Workers Compensation Reform Did
  • Antifraud legislation and increased penalties for
    fraud.
  • Anti-referrals that restricted physicians
    referring patients for diagnostic studies to
    sites where the physician has financial interest.
  • Proof of medical necessity for treatments, as
    well as appropriate medical documentation arose.
    Payers may refuse to pay the entire bill without
    medical documentation.

36
More Reform Measures
  • Preauthorization for major operations and
    expensive tests
  • Caps on vocational rehabilitation
  • Development of fee schedules
  • Medical bill review payer examination of
    duplicate claims and billing errors

37
The Process In Brief
  • Employee has an accident occurring within the
    course and scope of employment. Accidents can
    result in physical or mental injuries, but again,
    must be within the scope of employment.
  • Employee is treated at a healthcare provider.
  • The accident must be reported by the employers
    HR/administrator to both the state and insurance
    company. Failure to report may be against state
    law.
  • The healthcare provider must supply comprehensive
    information, and they also may have to report
    information to the state, depending on the law.
    (For instance, New York has a very involved state
    reporting process.)
  • The insurance company must receive accident
    reports, medical records, and bills in order to
    make judgment and pay the claim.

38
Out-of-State Claims
  • Follow all regulations from the jurisdiction in
    which the injured was hired, and not the state
    where the injury occurred
  • Companies with employees that travel must have
    policies that cover out of state injuries
  • If a patient seeks treatment out of state,
    referral requirements must be met
  • Unauthorized care holds the patient responsible
    in these states
  • Alabama
  • Alaska
  • Arkansas
  • New Jersey
  • North Dakota
  • Ohio
  • Washington
  • West Virginia
  • Wisconsin
  • Note Maritime employees do not fall under state
    workers compensation laws. Example Cruise ship
    employees injured at sea often have their medical
    bills paid in full, or negotiated with a maritime
    company that works with the cruise line.

39
Motor Vehicle Claim Processing
  • Best Practices Amidst Changing Times

40
Auto Claim Processing
  • The process of claim submission is similar to
    Work Comp in the following ways
  • Identify the injury
  • Identify the payer
  • Submit the claim to a specific adjuster who owns
    the claim
  • What is different is the amount of money
    available in an auto policy. It is NOT infinite.
    The policy WILL exhaust.
  • Each state has its own set of no-fault or tort
    processing and negligence rules. This determines
    which guy we chase. Our patient, or the other
    guys insurance.

41
Auto Claim Complexities
  • Layers of medical coverage may or may not exist
    on a patients policy. It all depends on what
    they bought on their declaration sheet from their
    insurance broker.
  • These layers include Personal Injury Protection
    and MedPay. Some states require one or the other.
    Some states require nothing at all. In Florida,
    like many states, MedPay coverage is optional to
    purchase. This is often a secret medical
    coverage not many are even aware of.
  • Its often hard to conduct patient interviews,
    plain and simple. These are often traumatic
    accidents. Many people want to hire a lawyer, and
    are hesitate to admit any kind of negligence. The
    process is usually unclear to the average patient
    and insurance consumer.

42
Legal Aspects of Auto Claims
  • Many times, patients hire private lawyers.
  • Once this happens, we know a settlement will
    happen in the future.
  • This ages a claim up to two years, sometimes
    more.
  • The hospital may or may not file a lien in
    Florida, and in cases where the county doesnt
    allow it, the hospital can request a Letter of
    Protection from the attorney, which is simply a
    courtesy letter from the attorney to show
    awareness of medical bills.
  • A long history of attorney communication can be
    helpful in future communications. Successful
    settlements happen through regular, diplomatic
    negotiations.
  • Information exchange and regular follow-up with
    attorneys is critical!

43
Florida PIP Reform
  • CS/HB 119 creates a new no-fault motor vehicle
    insurance system, the Emergency Care Coverage
    (ECC) Law, to revamp the personal injury
    protection (PIP) system.
  • While the ECC system represents a significantly
    different approach to no-fault law, it retains
    many aspects of PIP.
  • ECC is identical to PIP with respect to persons
    covered by the no-fault policy, the amount of
    mandated coverage (10,000), and the availability
    of lost wage and funeral benefits.

44
Review of PIP Reform So Far
  • Insurers in Florida may scrutinize their PIP
    payouts even more than ever. The top five that
    underwrite in Florida are State Farm, Berkshire
    Hathaway, Allstate, Progressive, and USAA. Expect
    more scrutiny with MVA-related medical bills.
  • ER services may increase, since the PIP law is
    requiring accident victims to be treated in the
    ER within 14 days of the accident.
  • Medical utilization review will increase by
    insurers.

45
Summary Analysis (House of Representatives)
  • In December 2011, there was an ICA publication
    Report on Florida Motor Vehicle No-Fault
    Insurance (Personal Injury Protection). The
    report contains data and information collected
    from various sources, including the OIR, National
    Association of Insurance Commissioners, Insurance
    Research Council, National Insurance Crime
    Bureau, Mitchell International, Inc., other state
    agencies, etc.
  • Among the reported findings
  • Strains and sprains were the most serious injury
    reported by 70 of PIP claimants.
  • The number of PIP claimants treated in emergency
    room settings declined from 57 in 1997 to 54 in
    2007.
  • In 2010, average charges per PIP claimant (by
    provider) were lowest for emergency medicine
    (1,613). The highest average charges per PIP
    claimant were by chiropractors (3,482),
    acupuncturists (3,674), and massage therapists
    (4,350).
  • The number of new massage therapist licenses
    increased from 2,843 in 2010 to an estimated
    4,892 in 2011.
  • The percentage of PIP claimants visiting
    chiropractors increased from 30 in 1997 to 43
    in 2007.

46
Summary Analysis (House of Representatives)
  • DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR for PIP
    REFORM
  • ECC policies provide a narrower range of coverage
    and curtail fraud in the no-fault system
  • The ECC Law will lower the premiums paid by
    Florida motorists for no-fault motor vehicle
    insurance.
  • Correspondingly, this bill will result in some
    medical providers not being paid from a
    traditional source, which may result in shifting
    some medical costs to health insurance providers,
    shifting some medical costs to individuals, and
    lower utilization of providers where individuals
    are unable or unwilling to pay for such medical
    care.
  • To the extent that medical care coverage policies
    provide a medical benefit of up to 2,500 for
    non-emergency conditions, rather than 10,000 as
    under current law, the medical care coverage Law
    will assist in lowering the premiums paid by
    Florida motorists for no-fault motor vehicle
    insurance.

47
Ancillary Points of the Bill
  • Massage and acupuncture benefits are completely
    excluded under the new PIP provisions.
  • Attorney multiplier fees have been repealed.
    Attorneys will therefore not have their fees
    multiplied in certain judgments.
  • Due to a rate rollback, (10 initially), more
    people may be covered by PIP. People will be more
    apt to buy policies and maintain their premium
    payments. In 2014, the rate rollback will be 25.
    The insurer must legally provide a detailed
    explanation if they cannot reduce someones rate.

48
Further Conclusions on PIP Reform
  • Expert-level insurance recovery is needed to
    garner PIP money
  • These bills will go through further scrutiny by
    auto insurers
  • Non-emergent coverage will cap at 2,500 and then
    most likely will kick into either the patients
    MedPay plan if purchased, then the patients own
    health plan, and if a health plan is unavailable,
    the claim may result in tort recovery with an
    at-fault Bodily Injury carrier.
  • Fraudulent claims may theoretically be minimized
    with this bill.
  • Medical utilization review will increase by
    insurers. It appears that care is limited in
    certain cases.
  • More legal cases/suits may possibly open up with
    legitimate complex injuries, since more treatment
    provisions are being listed in the legislation.

49
Links on PIP Reform
  • Text of Entire Bill http//flsenate.gov/Session/B
    ill/2012/0119/BillText/er/PDF
  • History and Analysis of Bill http//flsenate.gov/
    Session/Bill/2012/119

50
Billing Problems
  • Solutions to Common Issues, and Avoiding
    Underpayments and Denials

51
Billing Problems
  • Lack of medical records
  • Incorrect patient name
  • Duplicate statements
  • Illogical dates
  • Date of service prior to date of accident
  • Birthdate in the future
  • Facility Name Address incorrectly or not linked
    to facility Tax ID
  • Send documentation
  • Investigate patients name as it is on valid ID
    and insurance cards
  • Send corrected claims and appeals to the correct
    addressee it can get lost in the shuffle at any
    point
  • Correct dates
  • Send W-9 to Insurance

52
Denial Reasons
  • There are parts of the PIP Reform bill (HB 119)
    that give insurers many reason to
    administratively reject bills
  • Signature on File does not satisfy a providers
    signature
  • Provider License Numbers must be on every bill
    sent to the insurer
  • Service dates may not be more than 35 days before
    Postmark Date of the bill, unless there is
    written notification by the provider to the
    insurer.
  • An insurer may investigate a claim for validity,
    but a provider may charge interest while the
    investigation occurs. There must be a 30-day
    notice to the claimant by the insurer that an
    investigation is taking place. At the end of 30
    days, the insurer has 60 days to conclude the
    investigation. A payment or denial must therefore
    be made by the insurer within 90 days of claim
    submission with simple interest added.
  • Claim procedural relatedness to the injury
  • Medical necessity of services
  • Charges are in excess of what is permitted by the
    law

53
Unique Situations
  • Undocumented workers
  • Incarcerated individuals
  • Municipal workers
  • Burn liability claims
  • Discuss with employer how claim will be paid
  • Is a contract in place with local Department of
    Corrections? Will Medicaid pay?
  • Is the municipality self-insured, or insured by a
    carrier?
  • How did the burn occur? Source is important to
    determine payment!
  • Industrial Accident
  • Home
  • MVA
  • Crime Victims Compensation

54
Trick Question
  • Scenario
  • Jane Smith, a secretary, goes to the bank to
    deposit some money for her employer. While on the
    errand, Janes car is rear-ended by another car
    and she is injured. She is sent to the hospital.
  • Question
  • Who will pay the hospital bill?
  • Janes Auto Carrier
  • Other Drivers Auto Carrier
  • Workers Compensation Plan
  • Janes Health Plan
  • Jane Smith

55
Coordination of Benefits
  • Whos on First, Second, Third

56
One Layer at a Time Coordination of Benefits
  • Example
  • John is rear-ended on his way home from the
    grocery store. He is sent to the hospital, where
    his injuries are determined as critical. John
    lives in a no-fault state.
  • Johns personal auto policy kicks in first!
    (Personal Injury Protection)
  • Residual balances kick into his private health
    plan
  • John hires an attorney the final dollars come
    through from the at-fault settlement
  • The primary payer is the insurance plan that is
    billed first when more than one plan is in the
    picture.
  • The secondary payer is billed for remaining
    unpaid balances after the primary avenue is
    exhausted.

57
Further Layers Coordination of Benefits
  • The at-fault third party payer kicks in after the
    primary and secondary are applied. This can
    sometimes be very quick, depending on if the
    first two are even available.
  • Finally, after all insurance efforts are
    exhausted, the account becomes a patient-pay
    (self-pay) file.

58
Motor Vehicle Accidents COB No-Fault
  • In a No-Fault state, COB looks like this
  • PIP (Personal Injury Protection) pays first
  • Patients health plan pays second
  • At-fault third party pays third
  • Co-pays and deductibles can kick into patients
    Auto MedPay if available
  • No-Fault states in the US
  • Florida
  • Hawaii
  • Kansas
  • Kentucky
  • Massachusetts
  • Michigan
  • Minnesota
  • New Jersey
  • New York
  • North Dakota
  • Pennsylvania
  • Utah

59
Motor Vehicle Accidents COB Tort
  • In a tort state, COB looks like this
  • Patients own auto or at-fault third party can
    pay first
  • Subrogation between the insurance companies
    happens behind the scenes
  • Patients private health plan pays second
  • Settlement money usually is the third and final
    stage

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Motor Vehicle Accidents, no COB state
  • In a non-COB state, any payer may pay first
  • Final note on this topic if the claim ends up
    NOT being a true motor vehicle accident, then the
    financial class of the account should be
    converted to a health payer, and then ultimately
    to Self-Pay

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Workers Compensation COB
  • All Workers Compensation plans are inherently
    no-fault
  • The injured worker is not responsible for
    payments
  • The workers compensation carrier that insures
    the employer will absorb liability and pay
  • If the employer is self-insured, they will pay
  • Note ONLY if a claim ultimately ends up NOT
    being a true workers compensation situation,
    then it will be
  • A health plan responsibility, or
  • A self-pay claim, if no health plan is active

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Workers Compensation Tort Cases
  • Sometimes, a patient will opt out of the Workers
    Compensation plan entirely, and outright sue
    their employer for damages
  • Settlement money will be owed to the hospital
  • Conduct regular follow-up with the attorney
    representing the patient

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Challenging Insurers
  • Maximizing Reimbursement and Speeding up Payments

64
Delinquent or Slow Pay Claims
  • Affirm with the carrier that a clean claim was
    sent
  • Precert/Preauth done
  • Documentation received
  • Follow up in a timely manner (every 28 days)
  • Send in written tracer forms that ask where the
    claim is at in the adjudication process
  • Track all denials to learn what services are
    being denied, and which insurance companies are
    doing the denying
  • Send all high-dollar claims by certified mail
  • Open a grievance with the State Insurance
    Department if you dont get anywhere

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Payer Response
  • An Explanation of Benefits (EOB) is sent either
    electronically or by mail to the healthcare
    provider for each claim.
  • Payment is enclosed with the EOB.
  • The remarks on the EOB are the first indication
    of whether follow-up procedures are required for
    the claim.
  • In many underpaid/unpaid cases, the next action
    is to correct the claim information and either
    re-bill the claim, or file an appeal.

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Example of Appeal Letter Contractual Reduction
  • Dear Director of Claims,
  • It is our understanding that your company has
    released a partial payment on the referenced
    claim. It is our position that this claim has
    still not been reimbursed correctly and that
    additional benefits are due.
  • Please be advised, it is our position that
    contractual provisions stipulate a higher level
    of payment for this treatment. As a participating
    provider, we feel the following contractual
    language or fee schedule reference is applicable
    to this claim and justifies additional payment
  • Insert potentially applicable contractual
    language. Reference the page number or attach
    copy from contract to add as an attachment to
    appeal.
  • Our review of the provider contract does not
    reveal any language justifying the current level
    of payment. In order to assess the accuracy of
    payment, we request your response regarding how
    the payment was calculated ,and what portion of
    the fee schedule was utilized. It is our
    position that if terms of the contract are in
    direct conflict, the higher reimbursement should
    be allowed. As you are likely aware, many courts
    have ruled that managed care contracts are
    contracts of adhesion and that the organization
    responsible for drafting the contract wording can
    be responsible for unclear and ambiguous terms.
  • Based on this information, we ask that this claim
    be reviewed. We appreciate your prompt attention
    to this matter.
  • Sincerely,
  • Appeals Specialist

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Summary and Training Opportunities
  • What Weve Learned Today and Steps for the Future

68
Training Opportunities
  • Always educate the patient and take the stance of
    patient-friendliness
  • Have the patient fill out Assignment of Benefits
    forms in liability scenarios
  • ICD-10 training includes location of injuries,
    which will help ID Auto and Work Comp accidents
  • Keep a paperless paper trail by notating every
    detail of the claim cycle. Every detail helps.
  • Terms to Remember
  • Tort
  • Adjuster
  • Adjudication
  • Lien
  • Utilization Review
  • Silent PPO
  • Appeal
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