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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.

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Presentation on theme: "Recovery Best Practices for Motor Vehicle Accident and Worker’s Compensation Liability Claims Educational Session August 9, 2012 Greater Florida Buccaneer."— Presentation transcript:

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

2 Today’s 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 Worker’s Compensation Liability claims Training opportunities for Motor Vehicle Accident and Worker’s Compensation liability claims

3 Insurance companies want to know the thought processes physicians use to reach medical decisions. Payments for liability injuries, such as Worker’s 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. Times Have Changed

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 1. Patient presents to a facility 2. The collection of data for a medical claim begins at this time during check-in 3. The registrar or appointment scheduler collects and documents insurance information 4. 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. Lifecycle of a Liability Claim

6 The registrar is held accountable for identifying all possible payers (primarily insurance companies). During the patient’s 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.) Lifecycle of a Medical Claim, briefly

7 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. Lifecycle of a Medical Claim, continued

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?  Driver’s auto insurance company name  Other party’s 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 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 Registration: On-the-Job Injuries

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 Physician’s 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 Electronic submission (secure 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 adjuster’s name. Claim Submission Methods

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

14 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 Data Centers

15 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. Data Centers, continued

16 Example UB

17 Resulting EOB with errors

18 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 Adjudication

19 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! Bill Review and Pricing

20 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 Utilization Review

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 22

23 Negligence Rules and Insurance Policies No-fault state Pure comparative negligence (a person’s 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) 23 Courtesy: FL Department of Public Safety, FL Dept of Insurance

24 Florida Workplace Injuries 18,537,969 = Florida’s total population (2009) 7,018,700 = total employees in Florida (2010) 222,600 = total injuries 215 = total fatalities 10% unemployment rate 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 24 Courtesy: US Census; Bureau of Labor Statistics; Florida’s 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)) 25

26 Types of Reimbursement: National Overview All methodologies operate under various contracts, policies, and guidelines, that all depend on state and federal laws 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

27 APCs Capitation Case rate  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. Breaking the Methodologies Down

28 DRG Day Differentials Service Differentials 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. It’s 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 Courtesy: Marilyn Fordney; Medical Administrative Procedures Breaking the Methodologies Down

29 Fee Schedule Flat Rate Per Diem Managed Care stop loss outliers ◦ Case based outliers ◦ Reinsurance stop loss ◦ Percentage stop loss 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 don’t 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. Breaking the Methodologies Down

30 Worker’s Compensation Details Analyzing the Process

31 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 worker’s 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 worker’s compensation laws. They vary from state to state. This coverage is the most important coverage written to insure industrial accidents. A Very, Very Brief History

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

33 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 ◦ day payment timeline. Employers may violate this – there are no penalties for violation. Courteous but aggressive pursuit is a must. Self-Insured Employers

34 The Beginnings of Worker’s 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 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. What Worker’s Compensation Reform Did

36 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 More Reform Measures

37 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 employer’s 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. The Process – In Brief

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 worker’s 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 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 guy’s insurance.” Auto Claim Processing

41 Layers of medical coverage may or may not exist on a patient’s 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. It’s 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. Auto Claim Complexities

42 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 doesn’t 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! Legal Aspects of Auto Claims

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 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 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 someone’s 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 patient’s MedPay plan if purchased, then the patient’s 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: er/PDF er/PDF History and Analysis of Bill:

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 patient’s 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 provider’s 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 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 Unique Situations

54 Scenario: Jane Smith, a secretary, goes to the bank to deposit some money for her employer. While on the errand, Jane’s car is rear-ended by another car and she is injured. She is sent to the hospital. Question: Who will pay the hospital bill? A. Jane’s Auto Carrier B. Other Driver’s Auto Carrier C. Worker’s Compensation Plan D. Jane’s Health Plan E. Jane Smith Trick Question:

55 Coordination of Benefits Who’s on First, Second, Third…

56 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. 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.  John’s 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 One Layer at a Time: Coordination of Benefits

57 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. Further Layers: Coordination of Benefits

58 Motor Vehicle Accidents COB: No-Fault - In a No-Fault state, COB looks like this: -PIP (Personal Injury Protection) pays first -Patient’s health plan pays second -At-fault third party pays third -Co-pays and deductibles can kick into patient’s 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 In a tort state, COB looks like this: ◦ Patient’s own auto or at- fault third party can pay first ◦ Subrogation between the insurance companies happens behind the scenes ◦ Patient’s private health plan pays second ◦ Settlement money usually is the third and final stage Motor Vehicle Accidents COB: Tort

60 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 Motor Vehicle Accidents, no COB state

61 All Worker’s Compensation plans are inherently no-fault The injured worker is not responsible for payments The worker’s 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 worker’s compensation situation, then it will be: ◦ A health plan responsibility, or ◦ A self-pay claim, if no health plan is active Worker’s Compensation COB

62 Sometimes, a patient will opt out of the Worker’s 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 Worker’s Compensation Tort Cases

63 Challenging Insurers Maximizing Reimbursement and Speeding up Payments

64 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 don’t get anywhere Delinquent or Slow Pay Claims

65 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. Payer Response

66 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

67 Summary and Training Opportunities What We’ve Learned Today and Steps for the Future

68 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 Training Opportunities


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