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Report
How to create a sense of Urgency with Payers
Presented to the Wisconsin Revenue Cycle Co-Op/AAHAM
May 8, 2014
By Isaac S. Schreibman, Esq.
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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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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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Third Party Administrator
Adjuster
Repricer
Payer
Payment Review
PPO
“Silent” PPO
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PLAN ADMINISTRATOR
(EMPLOYER)
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Self-funded or group
(commercial ) carrier
Legally Responsible to
pay valid claims
Statutory (ERISA) and
contractual Liability
Authority to override
decision of TPA
BENEFIT
ADMINISTRATOR (TPA)
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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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“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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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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 UB
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 HCFA 1500
 Summary Plan Description
 Explanation of Benefits
 Assignment of Benefits
 Remittance/Denial
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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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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 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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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
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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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Date of
Accident/Injury
Type of injury
Location
Parties involved
Insurance coverage
Policy limits
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Adjuster assigned
Adjuster contact
information
Claim number
Date claim opened
Claim status
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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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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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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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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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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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Policy limits
Accident Reports
Results of Independent Medical Exams
Denial Letters
Requests for additional information
Copies of legal pleadings
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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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Use of certified mail
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Clear and concise cover letters for appeals
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Should be addressed to a specific person
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Use of supporting letters (treating physicians)
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Elaborate on medical records
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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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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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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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ERISA was enacted to protect the interests
of employee benefit plan participants and
their beneficiaries by:
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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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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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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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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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Internal appeals
External independent appeals
State administrative remedies
(Department of Insurance)
Prompt payment interest
Federal Court (ERISA)
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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
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Interest of 1% per month
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Office of the Commissioner of Insurance
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(608)-266-3585
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http://oci.wi.gov/ocihome.htm
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Questions and
Discussion
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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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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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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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Submitted detailed appeal with the following
appendix of supporting documents;
Authorization to Represent and Request for External Independent Review-executed by
Patient
Level II Appeal dated 8/6/2012
Operative and Discharge Reports
Bill submitted to Cigna for the procedure under appeal
Letter from treating surgeon
Explanation of Benefits for 4/2011 treatment
Letter from CIGNA dated 9/28/2012
Bibliography of clinical articles related to Transoral Incisionless Fundoplication (TIF)
procedure
TIF Clinical Results –EndoGastric Solutions
FDA Approval of Device (21 CFR § 876.1500)
Statement from the American Society of General Surgeons dated 4/1/2011
Letter from the Patient
Copies of specific articles cited in appeal letter and letter from treating surgeon
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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 Schreibman
The Law Office of Isaac
Schreibman
[email protected]
(847) 756-7606 (O)
(847) 970-8248 (C)
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