“PENDING ” IS NOT A STATUS
How to create a sense of Urgency with Payers
Presented to the Wisconsin Revenue Cycle Co-Op/AAHAMMay 8, 2014
By Isaac S. Schreibman, Esq.
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Overview
Delayed payment reduces the value of claims
Appreciate the importance of maintaining communication with the patient throughout the follow up process
Insure2 that claims and appeals are received in a timely manner
Identify and understand issues preventing prompt payment and overcoming obstacles to prompt payment
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Following up on Claims Understand the process Understand timeframes System knowledge Patient contact Detail driven Utilize available rights and remedies Identify “pressure points” Clearly explain expectations
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Roles and Responsibilities
PLAN ADMINISTRATOR (EMPLOYER)
BENEFIT ADMINISTRATOR (TPA)
Self-funded or group (commercial ) carrier
Legally Responsible to pay valid claims
Statutory (ERISA) and contractual Liability
Authority to override decision of TPA
Review and approve claims for payment
Engage “re-pricers” Process payment and
issue Explanation of Benefits
Attempt to access PPO networks (silent PPO)
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“Re-pricers” and other Strangers
“Silent PPOs” Identify re-pricers (can work for TPA) Detailed examination of the EOB Validate written agreements are in place Review Summary Plan Description Keep focus on the entity contractually
responsible for payment (e.g. health plan, employer)
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Insurer’s Coverage Position
Found on-line, not in policy Defines covered procedures as medically
necessary only when specific conditions are met
Detailed, lengthy and very complex Defines what treatments and procedures
have to be attempted before procedure in question will be approved as medically necessary
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Tools of the Trade
UB 04 HCFA 1500 Summary Plan Description Explanation of Benefits Assignment of Benefits Remittance/Denial
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Assignment of Benefits
An appropriate worded and properly executed Assignment of Benefits/Authorization to Represent is a powerful tool to be used when attempting to obtain meaningful status of claims and to resolve claims requiring additional information .
Many times the insurance representative will initially refuse to provide more detailed information than “claim pending” or “claim under investigation” claiming confidentiality concerns.
If there is a valid Assignment of Benefits in the file the provider’s representative should advise…
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Assignment of Benefits (continued)
The hospital is the Assignee of the patient’s insurance benefits and as such stands in the shoes of the patient and has all the rights and interests that the patient has regarding his insurance policy/claim. Let me fax a copy of the Assignment of Benefits to you. By executing that document the patient has given the Hospital the right to obtain information and documentation regarding their pending claim and to take any action necessary to enforce their claim.
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Assignment of BenefitsASSIGNMENT OF BENEFITS / ERISA AUTHORIZED REPRESENTATIVE FORM
The Hospital Assignment of Insurance Benefits I hereby assign my rights, title and interests in all applicable health insurance benefits to which I am entitled to (the Hospital). I certify that the health insurance information that I provided to the Hospital is accurate as of the date set forth below and that I am responsible for keeping it updated. I hereby authorize Provider to submit claims and appeal denied claims, on my behalf, to the benefit plan (or its administrator) as I provided to the Hospital, in good faith. I hereby authorize my benefit plan (or its administrator) to pay the Hospital directly for services rendered to me. If my current policy prohibits direct payment to Provider, I hereby instruct and direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and the Hospital upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make out the check to me and mail it directly to Provider. Authorization to Release Information I hereby authorize the Hospital and my benefit plan to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing. ERISA Authorization I hereby designate, authorize, and convey to The Hospital to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan: (1) the right and ability to act as my Authorized Representative in connection with any claim, right, or cause in action that I may have under such insurance policy and/or benefit plan; and (2) the right and ability to act as my Authorized Representative to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to, the right and ability to act as my Authorized Representative with respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. §2560.5031(b)(4) with respect to any healthcare expense incurred as a result of the services I received from the Hospital and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines, interest and attorney’s fees. A photocopy of this Assignment/Authorization shall be as effective and valid as the original. Patient Date Policyholder/Insured Date
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Rights of the Assignee To obtain a copy of the
Summary Plan Description (Policy Specifications)
To obtain a comprehensive listing of all policy exclusions, restrictions and limitations
To request that the insurer provide specific details concerning what steps they have taken to obtain required information/documentation,
To obtain copies of correspondence and documentation sent to the insured
To obtain copies of all legal notices sent to the insured or policy beneficiary
To obtain reports, records and other documents prepared in connection with the insurer’s review of a submitted claim
To exercise certain rights where the insured is deceased
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Confirming Claim Information
Date of Accident/Injury
Type of injury Location Parties involved Insurance
coverage Policy limits
Adjuster assigned Adjuster contact
information Claim number Date claim
opened Claim status
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Obtaining Claim Status
Identify the entity to whom you are speaking
What stage of the process is the claim in? What information or action is required to
complete the process? Who is responsible for the next action step? When will the next action be taken on the
claim?
“PENDING” IS NOT A STATUS!
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Claim Status (continued)
Obtain collateral information Clearly identify disputed issues
(coverage, treatment) Confirm outstanding issues in writing
(large balance accounts) Does the Patient have legal
representation? If so obtain attorney contact information
Request that the insurance representative confirm current, detailed status in writing
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Valid Statuses
Medical Records Required Information Required from Patients (COB
info) Patient Statements/Medical Exams
required (have they been scheduled, when)
Accident Reports (Liability/No-fault Claims)
Coverage/Liability Determinations
What can you do to assist with the process-especially patient contact!!
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Establish Denial Reason
Be wary of multiple (and inconsistent) denial reasons (e.g. not covered and charges not reasonable and customary)
Identify documentation and information required to overcome the denial (letter from treating physician)
Was the treating physician paid by the same carrier for the same service?
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Challenge yourself
Why should it take 90 days to pay a claim?
Who am I speaking with; insurance carrier, Third Party Administrator, Re-pricer?
Is the patient aware of the current status of their claim? When was the last contact with the patient? Keep the patient informed and involved
Do you have copies of all correspondence sent by the insurance company to the patient?
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If you don’t ask-you won’t get
Policy limits Accident Reports Results of Independent Medical
Exams Denial Letters Requests for additional information Copies of legal pleadings
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Written Communication
Faxes and Letters as alternatives to leaving messages
Letter of Representation/Authorization Detailed questionnaire to patient Request for information to attorney and
adjuster Request for written status from insurance
company
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Written Communication (continued)
Use of certified mail
Clear and concise cover letters for
appeals
Should be addressed to a specific person
Use of supporting letters (treating
physicians)
Elaborate on medical records
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Create a sense of Urgency
Confirm receipt of all correspondence within 72 hours
Suggest that claim be “escalated” (because of age, balance or disputed issue)
Clearly document a valid status, progress of claim review and anticipated next step
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Working with the Patient
Secure patient cooperation Become the patient’s advocate, not
adversary Confirm patient contact information (e-
mail and alternate telephone numbers) Obtain special authorization to
represent the patient Keep the patient in the loop Have the patient contact their benefit
coordinator
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Working with Employers
ERISA Plans
Employee Retirement Income Security Act of 1974 (ERISA) (Pub.L. 93–406
Self-funded
Group Carriers
Employers can override the decisions of their group carriers
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Working with Employers
ERISA was enacted to protect the interests of employee benefit plan participants and their beneficiaries by:
• Requiring the disclosure of financial and other information concerning the plan to beneficiaries;
• Establishing standards of conduct for plan fiduciaries;
• Providing for appropriate remedies and access to the federal courts.
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Working with Employers (continued)
Keep them involved in the process (advise them of adverse decisions of TPA or Group Carrier)
Employers can override decisions of TPA or Group Carrier
Engage patient and employer, throughout the entire process
Workers Compensation Cases (payment of outstanding medical bills)
Workers Compensation Denials
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When to Refer/Escalate Accounts
Patient represented by an Attorney Legal proceeding pending No payment or final disposition
within 120 days from bill date Conflict between multiple carriers Unsupported denials Additional information needed from
patient
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Utilizing Outside Counsel
Increase effectiveness in dealing with patients’ attorneys and insurance companies
Understand and resolve complex reimbursement issues
Increase level of intensity on high balance accounts
Sense of “urgency” Legal Action
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Administrative and Legal Remedies
Internal appeals External independent appeals State administrative remedies
(Department of Insurance) Prompt payment interest Federal Court (ERISA)
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Prompt Payment Requirements (WI)
Denial or payment of claims within 30 (calendar) days of submission of claim (§628.46)
Written notice of covered loss and amount of claim required
Interest of 1% per month Office of the Commissioner of Insurance
(608)-266-3585 http://oci.wi.gov/ocihome.htm
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Case Study 1- Insurance Under-Payment
Out of plan payer was billed for services provided to the patient in the amount of approximately $120,000
Hospital billed TPA and TPA engaged a repricer
Repricer paid the Hospital $27,000, 10 months after billing, claiming balance of charges were not “reasonable and customary”
Payer was a self-funded ERISA plan
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Case Study 1-Insurance Under-Payment
Hospital’s attorney demanded a copy of the employer’s Summary Plan Description. The Plan provided for payment of 100% of charges after patient met deductible and co-pay.
Using the Assignment of Benefits signed by the patient the Hospital filed a lawsuit against the employer in federal court based on the provisions of ERISA
The pending action seeks $88,000 in charges plus interest and attorney’s fees
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Case Study 2-Insurance Denial
Patient had relatively new procedure performed. Procedure was cheaper, faster and less intrusive.
Procedure was peer recognized and supported.
Internal appeals upheld the original denial and were exhausted.
Requested and received an independent external appeal –(PPACA)
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Case Study 2-Insurance Denial
Submitted detailed appeal with the following appendix of supporting documents;
Authorization to Represent and Request for External Independent Review-executed by PatientLevel II Appeal dated 8/6/2012Operative and Discharge ReportsBill submitted to Cigna for the procedure under appealLetter from treating surgeonExplanation of Benefits for 4/2011 treatmentLetter from CIGNA dated 9/28/2012Bibliography of clinical articles related to Transoral Incisionless Fundoplication (TIF) procedureTIF Clinical Results –EndoGastric Solutions FDA Approval of Device (21 CFR § 876.1500)Statement from the American Society of General Surgeons dated 4/1/2011Letter from the Patient Copies of specific articles cited in appeal letter and letter from treating surgeon
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Case Study 2-Insurance Denial
Original denial was upheld by Independent external review
Appealed to employer to override decision
Employer agreed and directed that claim be paid
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For copies of referenced material;
Ike SchreibmanThe Law Office of Isaac [email protected](847) 756-7606 (O)(847) 970-8248 (C)