“ Pending ” is not a status

1. “Pending ” is not a status 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.

2. Overview • Delayed payment reduces the value of claims • Appreciate the importance of maintaining communication with the patient throughout the follow up process • Insure2that claims and appeals are received in a timely manner • Identify and understand issues preventing prompt payment and overcoming obstacles to prompt payment

3. 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

4. Who’s Who Third Party Administrator Adjuster Repricer Payer Payment Review PPO “Silent”PPO

5. 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)

6. “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)

7. Summary Plan Description

8. 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

9. Tools of the Trade • UB 04 • HCFA 1500 • Summary Plan Description • Explanation of Benefits • Assignment of Benefits • Remittance/Denial

10. 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…

11. 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.

12. Assignment of Benefits

13. 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

14. 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

15. 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!

16. 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

17. 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!!

18. 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?

19. 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?

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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.

27. 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

28. 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

29. 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

30. Administrative and Legal Remedies • Internal appeals • External independent appeals • State administrative remedies (Department of Insurance) • Prompt payment interest • Federal Court (ERISA)

31. 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

32. Questions and Discussion

33. Case Studies

34. 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

35. 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

36. 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)

37. 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 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

38. 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

39. For copies of referenced material; Ike Schreibman The Law Office of Isaac Schreibman ike@ikeschreibmanlaw.com (847) 756-7606 (O) (847) 970-8248 (C)