Title: Tri-Service Denials Management Panel Session : W-1-1630

1. Title:Tri-Service Denials Management Panel Session: W-1-1630

2. Objectives Provide basic understanding of the rules that apply to Third Party Collection Program denials management Provide basic understanding of how health insurance benefits apply to Third Party Collection Program denials management Provide basic understanding of how effective denials management reduces Third Party Collection Program Aged Accounts Receivables Answer denials management questions

3. Overview 10 U.S.C 1095 and 32 C.F.R 220 Health Insurance Benefits Reducing your Accounts Receivables

4. 10 U.S.C 1095 and 32 C.F.R 220 • 10 United States Code 1095 • Established the Third Party Collection Program • Backbone of Denials Management • Contains broad language about how Third Party Payers reimburse MTF claims • 32 Code of Federal Regulations 220 • Implements 10 U.S.C. 1095 • Further defines the intent of 10 U.S.C. 1095 • 14 Sections Contain Specific Language • Sec 220.2 Statutory obligation of third party payers • Sec 220.3 Impermissible exclusions • Federal Digital System: http://www.gpo.gov/fdsys

5. Using 32 C.F.R 220 • Out of Network (OON) • 32 C.F.R 220.3(c)(4) – Exclusions Impermissible • Reduced Allowed Amount • 32 C.F.R 220.3(c)(4) – Exclusions Impermissible • Medicare EOB/RAs • 32 C.F.R 220.10(d) – Medicare EOB Not Required • Reduced Number Of Allowed Inpatient days • 32 C.F.R 220.4(c)((2)(iii) – Utilization Review Provisions • 32 C.F.R 220.8(b) – Reasonable Charges Established • Offsets/Take Backs • 32 C.F.R. 220.7(d) – A Third Party Payer May Not Offset

6. Health Insurance Benefits • 32 C.F.R 220.4–Permissible Terms and Conditions of Health Plan • Obtaining Benefits • Employer Group Number • Benefit Web sites, for example: www.opm.gov/insure/health/planinfo/index.asp • www.navinet.net • Documenting Benefits • Capture in software • Create a spreadsheet

7. Health Insurance Benefits • Using Benefits • Valid or Invalid • Service-Specific Guidelines • Responding to Invalid Denials • Letter Templates • Service-Specific Guidelines • Denials Not Resolved in Your Favor • 32 C.F.R 220.7: The United States has the right to institute and prosecute legal proceedings to enforce the provisions of 10 U.S.C 1095 • Referring invalid denials to Legal • Service-Specific Guidelines

8. Aged Accounts Receivable Effective denials management reduces Aged Accounts Receivables

9. Aged Accounts Receivable TPCP OUTPATIENT RATIOS Source: TMA UBO Metrics Report

10. Q&A Questions For Tri-Service Denials Management Panel

11. Summary Use 10 U.S.C 1095 and 32 C.F.R. 220 to effect payment Obtain health insurance benefits to properly identify valid and invalid denials An effective Denials Management Program reduces your Aged Accounts Receivables and increases your collected-to-billed ratio Contact your Service Representative for service-specific guidelines