Coordination of Benefits and Third Party Liability Access Training and Development

Course Objectives Learn : Which carrier is billed as the primary carrier. How to recognize a possible third party liability case. Medicare’s special secondary payer requirements. What a lien is and when one is used.

Introduction This course has two sections: Coordination of benefits. – –Which payer is primary when two or more plans exist. Third party cases, liability insurances, and using liens.

Coordination of Benefits A set of rules designed to determine who pays first when a patient is covered by more than one health plan. Follow insurance company’s instructions, if given. COB rules do not apply to individual and family plans. Purpose of the COB Rules: to prevent duplicate payments to a provider for the same service.

ADULTS and the COB rules When you have two plans, which is first? Subscribers plan is primary over any plan carrying them as a dependent. Subscriber plans: actively employed, unemployed or retired and covered by COBRA or a health plan. Subscribers employee health plan is primary over a plan that covers them as a retiree. Subscribers employee retirement health plan is primary over a plan that covers them under COBRA.

What is COBRA? CONSOLIDATED OMNIBUS BUDGET RECONCILATION ACT Created a right to continue your group health plan coverage if you’re laid off or your hours are reduced, causing a loss of health benefits for at least 18 months. COBRA is a continuation of your existing health plan benefits. – –COBRA protects you against pre-existing conditions. Once COBRA ends or if employer not eligible to offer it, you have a right to a conversion policy. – –This is a new policy, which can contain less benefits than the original plan. – –Protects you against pre-existing condition.

Children If the parents are together... use the birthday rule (month + day of birth)

Children If parents are NOT together… use the court decree If no court decree exists: 1. custodial parent 2. step-parent 3. non-custodial parent 4. non-custodial step-parent

Pregnant, Unmarried, Dependent, Daughter Parents’ insurance covers their daughter delivery May not cover the baby or cover just nursery stay

In General : COB Primary group plan pays according to it’s contract. The secondary carrier’s payment is the lesser of their contract rate or the primary’s contract rate. If one plan doesn’t have a COB provision, that plan pays first. –Most individual plans do not have a COB provision. If both have COB but disagree: –30 days to research then each plan pays 50/50 If neither have COB: –each pays 50% of the highest contract rate

Government Programs and COB 2. Medicare, unless less than 20 emp 4. Medi-Cal 2. Tricare or Tricare for Life 3. Medi-Cal 1. Medicare 1. Tricare2. Medi-Cal 1. Employer Group Health Plan 3. Tricare

Third Party Liability Patient has been injured. The injury is caused by a third party. The third party is held liable for the injuries.

13 Liability Coverage We are required by state and federal governments and by our insurance contracts to collect and document as much accident insurance as possible. Liability coverage includes: premise liability, auto coverage, med-pay plans, uninsured motorist, product liability.

LOOK AT THE DIAGNOSIS: some indicate an accident FracturesBruises Foreign bodies PoisoningsContusions Loss of consciousness Back and neck injuries

Types of liability Insurance Premise (property) liability insurance Property –Homeowners –Renters –Commercial

Automobile Coverage Automobile Coverage Automobile insurance – –Third party’s liability auto insurance – –Patient’s med-pay – –Uninsured motorist

Miscellaneous Liability Coverage Product liability Business coverage – –food poisoning – –slips and falls Medical malpractice – –treat wrong arm Student sports

Medicare’s Secondary Payer Requirements Medicare mandates our collection of accident information. – –Complete Medicare Secondary Payor and accident screens or document patients refusal to give information in ACOM. – –We must prove through documentation and the MSP screens that no other carrier is available to cover a Medicare patient’s medical expenses in order to bill Medicare.

Liens A lien is the right to take, hold, or sell the property of another to secure or repay a debt. The property we are interested in is a wrongdoer’s liability insurance.

How Does a Lien Work? The hospital files a lien for services if: – –a patient is injured as a result of an accident – –the patient sues a third party for his or her injuries The filed lien attaches to: – –accused third party’s liability insurance, and/or, – –potential jury award If patient settles out of court or collects in court, hospital may be able to collect the total amount of the lien.

Summary Coordination of Benefits (COB) –Determines which insurance pays first and how much is paid. Third Party Liability (TPL) –When the wrongdoer is held responsible for the patients injuries. –If liability insurance exists, we may choose to settle with an attorney or file a lien to recover the total charges of the medical services provided.