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From Registration to Accounts Receivable – The Whole Can of Worms

2007 UBO/UBUConference2007 UBO/UBUConference

Briefing: The JAG’s Role in the Third Party Collections & Policy

Date: 22 March 2007

Time: 0800 - 0850

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Objectives

Explain the legal office’s role in the UBO Claims programs, including policy and collections  

Explain the differences between civilian sector billing and collection rules, and how they may differ from, or impact the federal Third Party Collection Program (TPCP) (state prompt pay laws, etc.)

Explain when you should contact your legal office to discuss a payer issue

Review a few TPCP “issues” Update on a variety of recent legal collection initiatives

 

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable JAG’s Role

Policy– Issuing general policy on various issues

surrounding the TPCP per our interpretation of the statute and regulation

Collections– Seeking payments on disputed claims from payers

Refunds– Recommending whether to issue a refund

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Civilian Sector vs. DoD

Generally, the same billing and coding rules apply to MTFs

Use caution when deviating from a standard practice per the direction of an insurance company – and if you do, make sure you have the insurance company’s directive in writing!

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Civilian Sector vs. DoD

State Prompt Pay laws– Sometimes they apply (e.g., timeframe for a payer

to pay a “clean claim”)– Sometimes they do not (e.g., since there is a

federal interest rate, state interest rates do not apply)

Employee Retirement Income Security Act (ERISA)

Health Insurance Portability and Accountability Act (HIPAA)

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable When To Call Your Legal Office

Call or transfer claims to your Regional Claims Settlement Office (RCSO) (or our office if necessary):– When you have spotted a payer trend/practice and

the payer is not responding to your demands for payment

– Anytime you’re not sure if a payment or denial is correct

– Per the timeline and guidance issued from MEDCOM UBO (currently NLT 180 days from date of initial billing)

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable The PPO Issue

The “Preferred Provider Organization (PPO) provision” has expired– DoD needs statistics before they will try to revive it– MEDCOM UBO is developing a method to come up

with statistics

So…what does this mean?– Payers will pay a lower percentage rate because

the patient’s share will be higher– The percentage rate should be based on the billed

rate, however – not a Usual, Customary & Reasonable or Blended Rate

– Any “unusual” PPO issues that pop up – discuss with your legal office

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Medicare Secondary Issue

32 C.F.R. 220.3(c)(5) prohibits a payer from paying an amount that would be secondary to a non-existent Medicare payment … UNLESS the plan:– expressly disallows payment as the primary payer

to all providers to whom payment would not be made under Medicare; AND

– is otherwise in accordance with applicable law

-Continued-

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Medicare Secondary Issue

There are times when payers have to pay primary; e.g., it’s an employee group plan, and the policyholder (patient or spouse) is still working – If you receive a secondary payment, you need to do

some homework and submit an appeal to the plan asking for additional information (if needed)

Refund requests: you don’t have to issue a refund on every claim that was paid primary in the past – There are legal arguments for keeping the

overpayment (e.g., doctrine of laches – they waited too long to ask for it)

– See your legal office if unsure of whether you need to issue a refund, especially if over 9 months since payment received

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Settlement Authority

The MEDCOM Office of the Staff Judge Advocate and Regional Claims Settlement Offices (RCSOs) each have $100,000 termination/compromise authority per claim

The Department of Justice (DOJ) has to approve terminations/compromises on claims over that amount

This does not mean all claims must go to your legal office to be closed. Please see MEDCOM UBO closure code spreadsheet and guidance regarding which claims have to be forwarded

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Recent Collection Initiatives

Medco– Resulted in over $2 million to DoD MTFs in 2005

and Dec 2006/Jan 2007

Mailhandlers– Remittances did not clearly explain denial reason;

follow-up revealed they were paying patients due to new software

– Agreed to search for and re-process claims for all DoD MTFs

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Recent Collection Initiatives

Humana– Paid $957/day instead of DRG– Great Plains RCSO is negotiating a settlement

Caremark– Modified two of their automation systems to print

patient’s last name on explanation of benefits– Phone contact for eligibility and claim status info– Letter – not contracted to adjudicate government

claims – MTF should contact plan and mail claim directly to plan

– Letter – No longer processes paper claims for benefit plan – Caremark is not contracted to process paper claims for this plan – contact plan and mail claim to address as per plan

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Summary

We’re from the JAG office, and we’re here to help!

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Quiz

When should you call your legal office with a question?

Should you issue a refund every time a payer requests one?

When do claims need to be transferred to your legal office for resolution, if still in dispute?