Transcript Recovery Best Practices for Motor Vehicle Accident and

Recovery Best Practices for Motor Vehicle
Accident and Worker’s Compensation
Liability Claims
Educational Session
August 9, 2012
Greater Florida Buccaneer Chapter
Today’s Discussion Points

Action steps to take beginning at the point of registration
on accident and motor vehicle claims

The impact of state and federal laws

Why hospitals may not be maximizing recoveries on
Motor Vehicle Accident and Worker’s Compensation
Liability claims

Training opportunities for Motor Vehicle Accident and
Worker’s Compensation liability claims
Times Have Changed

Insurance companies want to know the
thought processes physicians use to
reach medical decisions.

Payments for liability injuries, such as
Worker’s Compensation injuries, are
rarely paid without medical justification.

Clinical documentation and wellcompleted forms can assist providers in
meeting complex insurance and statedriven requirements.
High Touch Claims = High Cost Claims

Anytime a reduced payment or no
payment is received, the cost for
billing the services rises dramatically.

These extra costs reduce the profit for
the service.

The basic process to correctly fill out
a claim form and submit to any
insurance company is fairly similar,
but each payer can be very specific in
their individual needs.
Lifecycle of a Liability Claim
1.
Patient presents to a facility
2.
The collection of data for a
medical claim begins at this time
during check-in
3.
The registrar or appointment
scheduler collects and documents
insurance information
4.
The most important aspects of the
medical claim cycle occur between
the time the patient arrives at the
facility and the time the medical
claim is generated. It can be the
shortest part of the entire revenue
lifecycle, but also the most
important.
Note: Many points exist in
the cycle for a claim to
get lost or go awry.
Lifecycle of a Medical Claim, briefly

The registrar is held accountable
for identifying all possible payers
(primarily insurance companies).

During the patient’s evaluation,
the physician is responsible for
documenting the details of the
encounter.

Dramatic changes will occur from
the ICD-9 structure to ICD-10.
(More on that later.)
Lifecycle of a Medical Claim, continued

Most hospitals share software systems from
department to department and campus to
campus.

Typically, the hospital business office is able to
view insurance information garnered by upfront registration.

The quality and accuracy of billing information
and clinical documentation (as it flows through
each department) has the single greatest
impact on the quality of the claim.
Best Practices
Overview on Claim Handling to Achieve Greater Performance
Registration: Motor Vehicle Accident


Patient able to communicate:
◦ Role of patient in accident?
 Driver
 Passenger
 Pedestrian
 Bicyclist/Motorcyclist
◦ Insurance company known?
 Driver’s auto insurance company name
 Other party’s auto insurance name
 Own health insurance as secondary plan
Patient unable to communicate:
◦ Conduct patient interview retroactively
◦ Where appropriate, conduct data gathering with family/next of
kin
◦ Do not default financial class to Self-Pay
◦ Verify patient eligibility and benefits under auto and health plans
Registration: On-the-Job Injuries

Patient able to communicate:
◦ Employer name
◦ Employer address and main phone number
◦ Date of Accident
◦ Basic Injury, Body Part
◦ Employer HR/Manager/Foreman name and number

Patient unable to communicate:
◦ If patient was brought in with coworkers or
supervisor, gather same data
◦ Employer must file accident report with insurance
carrier and state industrial accident board
◦ Conduct interview with employer retroactively
◦ Do not default financial class to Self Pay
◦ If insurance carrier is known when patient presents
to facility, call insurance for service authorization as
soon as possible
Treatment Documentation
Substantiates services
 Charges will be
understood at insurance
company
 Validates necessity of
treatment
 Speeds up bill payment
when packaged together
(bills plus charts sent)
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Nurses’ notes
Physician’s report
◦ History and Physical
Lab reports
Radiology reports
Therapy:
◦ Physical
◦ Behavioral
◦ Speech
Durable Medical Equipment
Implant Invoices
Drugs administered
Itemization of all services rendered
Claim Submission Methods



Electronic submission (secure 837-5010 format)
◦ State compliance rules in place:
 Texas
 California
 Minnesota
 Illinois
 New York
◦ Payer capability (unique to each)
 Some are set up to accept electronic
submissions
Paper Submission
◦ Red 1500s or UBs
◦ Black and White forms mostly acceptable;
can be rejected quite often
Fax Directly to Auto or Work Comp Adjuster
 Note: Always
record submission
date and location of
where the bill and
records were sent.
This includes the
specific adjuster’s
name.
At the Insurance Company
What Happens to the Bill and Records
Data Centers



Many major Property and Casualty insurers have
standalone data centers
◦ Central mailing point
 Mail opened and categorized by type
 All mail is scanned into their system
 Claim numbers found if not on documents
 Document sent electronically to each appropriate
adjuster across the country
Note: having claim numbers on documents before
mailing saves an average of 21 days of processing at the
insurance company (really!)
Note: If no claim number was opened or found, claim will
be rejected. Employer must file accident report.
◦ Sometimes data centers are within the US or offshored
◦ It is not customary to contact data centers directly for
claim status
Data Centers, continued

Medical bills
◦ Red paper is scanned
◦ Red lines are “dropped out” by
scanners’ pixel interpretation
◦ Raw data is automatically fed to bill
review systems
 Less errors, but still imperfect
◦ Black and white bills are manually
data entered
 Slower processing time
 Prone to more errors in data entry
 Always double check EOBS for
insurance- rep errors.
Example UB
Resulting EOB with errors
Adjudication

Determination
◦ Adjuster Review – and/or –
◦ Automated Rules Engine
 Based on accident report and
severity of injury, adjuster
will set up rules that will
automatically “OK to Pay”
certain services, taking the
human element out of
manual examination
 Usually done with lower
balance, less complex claims

The role of the
adjuster is threefold:
◦ Own claim from start
to finish
◦ Examine claim validity
and any evidence of
fraud
◦ Reduce insurance loss
by predicting value of
overall claim
Bill Review and Pricing

Managed Care departments exist
 A few words on “Silent PPOs”
in the Property/Casualty
insurance environment!
◦ When a claim is paid, an
Explanation of Benefits (EOB)
◦ Line-by-line re-pricing of bills
occurs using various methods
is issued with the check
 PPO contracts
◦ The rationale of payment
 Fee schedule
should indicate if a contractual
 Usual and Customary
agreement was used
guidelines
◦ Does the facility really have a
 Nurse case management
contract in place with the PPO
 DRG (not line-by-line
mentioned on the EOB?
analysis; rather a fixed code)
◦ Challenge the insurer if not!
 Many other methodologies
Utilization Review
As many hospitals have UR
departments, insurance
companies do too.
 Nurses and doctors are
retained on staff to
investigate medical
necessity and claim
validity, especially for high
balance and complex
situations

 They examine clinical
documentation against
services listed on the bill
 They have conversations with
hospital physicians to
question or dispute certain
services and tests
 They reduce insurance loss by
disputing or denying coverage
based on clinical knowledge
Reimbursement Methods: Florida
How a Claim is Paid (or Not)
How Bills Are Valued
Work Comp Inpatient: Per Diem or
75% of charges if stop loss exceeded
for Acute Care Hospitals/Trauma
Centers.
 Work Comp Outpatient: 75% of
charges for emergency room
services, 60% of charges for
scheduled outpatient surgeries.
Otherwise, specified codes paid to
fee schedule, all others 75% of
charges.
 MVA Inpatient: Non emergency 200% of CMS DRG methodology.
 MVA Outpatient: Non emergency 200% of CMS APC methodology

•22
Negligence Rules and Insurance Policies
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No-fault state
Pure comparative negligence
(a person’s own percentage
of negligence is uncollectible
by him/her)
Coordination of Benefits
rules in place
By county hospital liens in
place
Escalation points available if
auto payers are
uncooperative

Statistics:
◦ MVA Injuries: 195,104 (2010)
◦ Fatalities: 2,444 (2010)
◦ Avg. crashes per day: 645

Insurance:
◦ $10,000 bodily injury per
person
◦ $20,000 bodily injury per
accident (Personal Injury
Protection = PIP)
Courtesy: FL Department of Public Safety, FL Dept of Insurance
•23
Florida Workplace Injuries

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18,537,969 = Florida’s total
population (2009)
7,018,700 = total employees in
Florida (2010)
222,600 = total injuries
215 = total fatalities
10% unemployment rate

Major employers in Florida:
◦ Alamo Rental
◦ Anheiser-Busch
◦ Carnival Cruise Lines
◦ Charter One Hotels & Resorts
◦ Citrix Systems
◦ Eckerd Drug Stores
◦ Florida Power and Light
◦ Publix Grocery
◦ Ryder Trucks
◦ Steinmart
◦ Tropicana
◦ US Sugar Corporation
◦ Wal-Mart
◦ Walt Disney
◦ Wellcraft
Courtesy: US Census; Bureau of Labor Statistics; Florida’s Largest Employers: Job Bank USA
•24
Florida Bill Payment Timeliness

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The insurer has 45 days to pay or
explain reason for non-payment
of medical claims. (FL Stat
§440.20(2-b))
The insurer has 120 days to either
pay or deny a disputed medical
claim. (FL Stat §440.20(4))
Hospitals must notify insurers
that they rendered emergency
care within 24 hours of admitting
an employee, and 3 days in nonadmission cases. (FL Stat
§440.13(3-b))
25
Types of Reimbursement: National Overview
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All methodologies
operate under
various contracts,
policies, and
guidelines, that all
depend on state
and federal laws
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APCs
Capitation
Case rate
DRG
Day Differentials
Service Differentials
Fee Schedule and Timely Pay Fee Schedules
Flat Rate
Per Diem
Managed Care stop loss outliers
◦ Case based outliers
◦ Reinsurance stop loss
◦ Percentage stop loss
At Charges
Sliding scale discounts
Breaking the Methodologies Down

APCs
 Capitation
 Case rate



Ambulatory Payment Classifications: Based on PROCEDURES,
not diagnoses. Services are assigned a group code:
 Surgical
 Significant procedures
 Medical
 Ancillary
 Note: Modifiers are important to clarify multiple services!
Capitation/Percent of Revenue: Reimbursement to the
hospital on a per-member, per-month basis regardless of
hospitalization. Percent of Revenue is a fixed rate of payment.
Case Rate: Averaging after a flat rate for a service has been
given to certain categories of procedures. Specialty
procedures may be given a case rate (e.g., graft surgery).
Bundled case rate is an all-inclusive rate for institutional and
professional services connected with the procedure.
Breaking the Methodologies Down
Diagnosis-related groups: A classification system that categorizes
patients who are medically related, with respect to diagnosis and
treatment. They are statistically similar in length of hospital stay. It’s
a lump-sum, fixed-fee based on diagnoses. Fees are made by a
research team, which determine national averages. DRG numbers go
from 001 to 900. Variables in DRG classification:
◦ Principal Diagnosis; Secondary diagnosis (up to eight)
◦ Surgical procedures (up to six)
◦ Comorbidity (pre-existing conditions) and complications
◦ Age and sex
◦ Discharge status
◦ Number of hospital days for a specific diagnosis
 Day Differential: First day paid at higher rate, cascading down each
following day.
 Service Differential: Hospital receives a flat per-admission
reimbursement for the service. A prorated payment can be made
(e.g., 50% ICU, 50% medical services) Services are defined in the
contract

DRG
 Day
Differentials
 Service
Differentials

Courtesy: Marilyn Fordney; Medical Administrative Procedures
Breaking the Methodologies Down

Fee Schedule
 Flat Rate
 Per Diem
 Managed Care stop
loss outliers
◦ Case based outliers
◦ Reinsurance stop
loss
◦ Percentage stop
loss
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Fee schedule: list of charges based on procedure codes.
Fee-for-service basis.
Flat Rate: A set amount per hospital admission regardless
of cost of actual services
Per diem: single charge for a day in the hospital, regardless
of actual charges or costs
Case-based stop loss: A mechanism of hospital and
insurance carrier sharing loss. It is a payment of a
percentage over a certain dollar threshold (e.g., 65% of
excess billing over $100,000.)
Reinsurance stop loss: The hospital buys insurance to
protect against lost revenue and receives less of a cap fee.
The amount they don’t receive helps pay for the
reinsurance. Example: A case reaches $100,000. The plan
may allow 80% of expenses in excess of that figure for the
rest of the year.
Percentage stop loss: A percentage paid of charges when a
certain threshold is met.
Worker’s Compensation Details
Analyzing the Process
A Very, Very Brief History

Workers in the late 1800s had it tough. For injuries and
deaths, the legal processes were uncertain. Negligence had to
be proven on the part of the employee.

In 1911, the first worker’s compensation laws were adopted
by many states. The laws allowed injured workers to receive
medical care without first taking employers to court.

All states currently have worker’s compensation laws. They
vary from state to state.

This coverage is the most important coverage written to
insure industrial accidents.
Types of Coverage

Two kinds:
◦ Federal compensation laws
 Applies to miners, maritime workers, and government workers
◦ State compensation laws
 State and private business employees
Self-Insured Employers
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Employers pay for medical expenses directly instead of
insurance premiums
Precertification is important – the self-insured employer is
very mindful of treatment costs
Self-insured employers are covered by ERISA (Employee
Retirement Income Security Act.)
◦ Mandates reporting
◦ Not state regulated – is under federal jurisdiction
◦ 90-105 day payment timeline. Employers may violate this –
there are no penalties for violation. Courteous but
aggressive pursuit is a must.
The Beginnings of Worker’s Compensation Reform

By 1994, dysfunction Work Comp systems were costing
companies more than $65 billion annually in many US
cities.

Insurers began denying coverage to businesses.

Some businesses began relocating to states allowing
lower premiums.

Widespread legal and medical corruption and abuse
evolved throughout the system.
What Worker’s Compensation Reform Did

Antifraud legislation and increased penalties for
fraud.

Anti-referrals that restricted physicians referring
patients for diagnostic studies to sites where the
physician has financial interest.

Proof of medical necessity for treatments, as well as
appropriate medical documentation arose. Payers
may refuse to pay the entire bill without medical
documentation.
More Reform Measures
Preauthorization for major operations and expensive
tests
 Caps on vocational rehabilitation
 Development of fee schedules
 Medical bill review – payer examination of duplicate
claims and billing errors

The Process – In Brief

Employee has an accident occurring within the course and scope of
employment. Accidents can result in physical or mental injuries, but
again, must be within the scope of employment.

Employee is treated at a healthcare provider.

The accident must be reported by the employer’s HR/administrator to
both the state and insurance company. Failure to report may be against
state law.

The healthcare provider must supply comprehensive information, and
they also may have to report information to the state, depending on the
law. (For instance, New York has a very involved state reporting process.)

The insurance company must receive accident reports, medical records,
and bills in order to make judgment and pay the claim.
Out-of-State Claims
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Follow all regulations from the jurisdiction in which the injured was hired, and not the
state where the injury occurred
Companies with employees that travel must have policies that cover out of state
injuries
If a patient seeks treatment out of state, referral requirements must be met
Unauthorized care holds the patient responsible in these states:
◦ Alabama
◦ Alaska
 Note: Maritime employees do not fall under state
◦ Arkansas
worker’s compensation laws. Example: Cruise ship
◦ New Jersey
employees injured at sea often have their medical
◦ North Dakota
bills paid in full, or negotiated with a maritime
◦ Ohio
company that works with the cruise line.
◦ Washington
◦ West Virginia
◦ Wisconsin
Motor Vehicle Claim Processing
Best Practices Amidst Changing Times
Auto Claim Processing

The process of claim submission is similar to
Work Comp in the following ways:
◦ Identify the injury
◦ Identify the payer
◦ Submit the claim to a specific adjuster
who owns the claim

What is different is the amount of money
available in an auto policy. It is NOT infinite.
The policy WILL exhaust.

Each state has its own set of no-fault or tort
processing and negligence rules. This
determines which “guy” we chase. Our
patient, or the “other guy’s insurance.”
Auto Claim Complexities

Layers of medical coverage may or may not
exist on a patient’s policy. It all depends on
what they bought on their declaration
sheet from their insurance broker.
◦ These layers include Personal Injury
Protection and MedPay. Some states
require one or the other. Some states
require nothing at all. In Florida, like
many states, MedPay coverage is
optional to purchase. This is often a
“secret medical coverage” not many are
even aware of.

It’s often hard to conduct patient
interviews, plain and simple. These are
often traumatic accidents. Many people
want to hire a lawyer, and are hesitate to
admit any kind of negligence. The process
is usually unclear to the average patient
and insurance consumer.
Legal Aspects of Auto Claims

Many times, patients hire private lawyers.

Once this happens, we know a settlement will happen in the future.

This ages a claim up to two years, sometimes more.

The hospital may or may not file a lien in Florida, and in cases where the county
doesn’t allow it, the hospital can request a Letter of Protection from the
attorney, which is simply a courtesy letter from the attorney to show awareness
of medical bills.

A long history of attorney communication can be helpful in future
communications. Successful settlements happen through regular, diplomatic
negotiations.

Information exchange and regular follow-up with attorneys is critical!
Florida PIP Reform

CS/HB 119 creates a new no-fault motor vehicle insurance system, the
Emergency Care Coverage (ECC) Law, to revamp the personal injury
protection (PIP) system.

While the ECC system represents a significantly different approach to
no-fault law, it retains many aspects of PIP.

ECC is identical to PIP with respect to persons covered by the no-fault
policy, the amount of mandated coverage ($10,000), and the
availability of lost wage and funeral benefits.
Review of PIP Reform So Far:

Insurers in Florida may scrutinize their PIP payouts even
more than ever. The top five that underwrite in Florida
are: State Farm, Berkshire Hathaway, Allstate,
Progressive, and USAA. Expect more scrutiny with MVArelated medical bills.

ER services may increase, since the PIP law is requiring
accident victims to be treated in the ER within 14 days
of the accident.

Medical utilization review will increase by insurers.
Summary Analysis (House of Representatives)
In December 2011, there was an ICA publication: “Report on Florida Motor Vehicle No-Fault
Insurance (Personal Injury Protection).” The report contains data and information collected from
various sources, including the OIR, National Association of Insurance Commissioners, Insurance
Research Council, National Insurance Crime Bureau, Mitchell International, Inc., other state
agencies, etc.
Among the reported findings:
 Strains and sprains were the most serious injury reported by 70% of PIP claimants.
 The number of PIP claimants treated in emergency room settings declined from 57% in 1997
to 54% in 2007.
 In 2010, average charges per PIP claimant (by provider) were lowest for emergency medicine
($1,613). The highest average charges per PIP claimant were by chiropractors ($3,482),
acupuncturists ($3,674), and massage therapists ($4,350).
 The number of new massage therapist licenses increased from 2,843 in 2010 to an
estimated 4,892 in 2011.
 The percentage of PIP claimants visiting chiropractors increased from 30% in 1997 to 43% in
2007.
Summary Analysis (House of Representatives)
DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR for PIP REFORM:
 ECC policies provide a narrower range of coverage and curtail fraud in the nofault system

The ECC Law will lower the premiums paid by Florida motorists for no-fault
motor vehicle insurance.

Correspondingly, this bill will result in some medical providers not being paid from
a traditional source, which may result in shifting some medical costs to health
insurance providers, shifting some medical costs to individuals, and lower
utilization of providers where individuals are unable or unwilling to pay for such
medical care.

To the extent that medical care coverage policies provide a medical benefit of up
to $2,500 for non-emergency conditions, rather than $10,000 as under current
law, the medical care coverage Law will assist in lowering the premiums paid by
Florida motorists for no-fault motor vehicle insurance.
Ancillary Points of the Bill

Massage and acupuncture benefits are completely excluded
under the new PIP provisions.

Attorney multiplier fees have been repealed. Attorneys will
therefore not have their fees multiplied in certain judgments.

Due to a rate rollback, (10% initially), more people may be
covered by PIP. People will be more apt to buy policies and
maintain their premium payments. In 2014, the rate rollback
will be 25%. The insurer must legally provide a detailed
explanation if they cannot reduce someone’s rate.
Further Conclusions on PIP Reform

Expert-level insurance recovery is needed to garner PIP money

These bills will go through further scrutiny by auto insurers

Non-emergent coverage will cap at $2,500 and then most likely will kick into
either the patient’s MedPay plan if purchased, then the patient’s own health plan,
and if a health plan is unavailable, the claim may result in tort recovery with an atfault Bodily Injury carrier.

Fraudulent claims may theoretically be minimized with this bill.

Medical utilization review will increase by insurers. It appears that care is limited
in certain cases.

More legal cases/suits may possibly open up with legitimate complex injuries,
since more treatment provisions are being listed in the legislation.
Links on PIP Reform

Text of Entire Bill:
http://flsenate.gov/Session/Bill/2012/0119/BillText/
er/PDF

History and Analysis of Bill:
http://flsenate.gov/Session/Bill/2012/119
Billing Problems
Solutions to Common Issues, and Avoiding Underpayments and Denials
Billing Problems
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Lack of medical records
Incorrect patient name
Duplicate statements
Illogical dates
◦ Date of service prior to
date of accident
◦ Birthdate in the future
Facility Name & Address
incorrectly or not linked to
facility Tax ID
 Send documentation
 Investigate patient’s
name
as it is on valid ID and
insurance cards
 Send corrected claims and
appeals to the correct
addressee – it can get lost in
the shuffle at any point
 Correct dates
 Send W-9 to Insurance
Denial Reasons
There are parts of the PIP Reform bill (HB 119) that give insurers many reason to
administratively reject bills:
◦ “Signature on File” does not satisfy a provider’s signature
◦ Provider License Numbers must be on every bill sent to the insurer
◦ Service dates may not be more than 35 days before Postmark Date of the bill,
unless there is written notification by the provider to the insurer.
◦ An insurer may investigate a claim for validity, but a provider may charge
interest while the investigation occurs. There must be a 30-day notice to the
claimant by the insurer that an investigation is taking place. At the end of 30
days, the insurer has 60 days to conclude the investigation. A payment or
denial must therefore be made by the insurer within 90 days of claim
submission with simple interest added.
◦ Claim procedural relatedness to the injury
◦ Medical necessity of services
◦ Charges are in excess of what is permitted by the law
Unique Situations
Undocumented
workers
 Incarcerated
individuals
 Municipal workers
 Burn liability
claims

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
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Discuss with employer how claim will be
paid
Is a contract in place with local Department
of Corrections? Will Medicaid pay?
Is the municipality self-insured, or insured
by a carrier?
How did the burn occur? Source is
important to determine payment!
Industrial Accident
Home
MVA
Crime Victims’ Compensation
Trick Question:
Scenario:
Jane Smith, a secretary,
goes to the bank to
deposit some money for
her employer. While on
the errand, Jane’s car is
rear-ended by another car
and she is injured. She is
sent to the hospital.
Question:
Who will pay the hospital
bill?
A. Jane’s Auto Carrier
B. Other Driver’s Auto
Carrier
C. Worker’s
Compensation Plan
D. Jane’s Health Plan
E. Jane Smith
Coordination of Benefits
Who’s on First, Second, Third…
One Layer at a Time: Coordination of Benefits


The primary payer is
the insurance plan that
is billed first when more
than one plan is in the
picture.

The secondary payer is
billed for remaining
unpaid balances after
the primary avenue is
exhausted.
Example:
◦ John is rear-ended on his way home from
the grocery store. He is sent to the
hospital, where his injuries are
determined as critical. John lives in a nofault state.
 John’s personal auto policy kicks in
first! (Personal Injury Protection)
 Residual balances kick into his private
health plan
 John hires an attorney – the final
dollars come through from the at-fault
settlement
Further Layers: Coordination of Benefits

The at-fault third party
payer kicks in after the
primary and secondary are
applied. This can
sometimes be very quick,
depending on if the first
two are even available.

Finally, after all insurance
efforts are exhausted, the
account becomes a
patient-pay (self-pay) file.
Motor Vehicle Accidents COB: No-Fault
-
In a No-Fault state, COB
looks like this:
- PIP (Personal Injury
Protection) pays first
- Patient’s health plan pays
second
- At-fault third party pays
third
- Co-pays and deductibles
can kick into patient’s
Auto MedPay if available

No-Fault states in the US:
◦ Florida
◦ Hawaii
◦ Kansas
◦ Kentucky
◦ Massachusetts
◦ Michigan
◦ Minnesota
◦ New Jersey
◦ New York
◦ North Dakota
◦ Pennsylvania
◦ Utah
Motor Vehicle Accidents COB: Tort

In a tort state, COB looks
like this:
◦ Patient’s own auto or atfault third party can pay first
◦ Subrogation between the
insurance companies
happens behind the scenes
◦ Patient’s private health plan
pays second
◦ Settlement money usually is
the third and final stage
Motor Vehicle Accidents, no COB state

In a non-COB state, any
payer may pay first

Final note on this topic: if
the claim ends up NOT
being a true motor vehicle
accident, then the financial
class of the account should
be converted to a health
payer, and then ultimately
to Self-Pay
Worker’s Compensation COB




All Worker’s Compensation
plans are inherently no-fault
The injured worker is not
responsible for payments
The worker’s compensation
carrier that insures the
employer will absorb liability
and pay
If the employer is selfinsured, they will pay

Note: ONLY if a claim
ultimately ends up
NOT being a true
worker’s
compensation
situation, then it will
be:
◦ A health plan
responsibility, or
◦ A self-pay claim, if no
health plan is active
Worker’s Compensation Tort Cases



Sometimes, a patient will
opt out of the Worker’s
Compensation plan
entirely, and outright sue
their employer for damages
Settlement money will be
owed to the hospital
Conduct regular follow-up
with the attorney
representing the patient
Challenging Insurers
Maximizing Reimbursement and Speeding up Payments
Delinquent or Slow Pay Claims
Affirm with the carrier that
a clean claim was sent
◦ Precert/Preauth done
◦ Documentation received
 Follow up in a timely
manner (every 28 days)
 Send in written tracer
forms that ask where the
claim is at in the
adjudication process




Track all denials to learn
what services are being
denied, and which
insurance companies are
doing the denying
Send all high-dollar claims
by certified mail
Open a grievance with the
State Insurance Department
if you don’t get anywhere
Payer Response

An “Explanation of Benefits” (EOB) is sent either electronically or by mail
to the healthcare provider for each claim.

Payment is enclosed with the EOB.

The remarks on the EOB are the first indication of whether follow-up
procedures are required for the claim.

In many underpaid/unpaid cases, the next action is to correct the claim
information and either re-bill the claim, or file an appeal.
Example of Appeal Letter: Contractual Reduction
Dear Director of Claims,
It is our understanding that your company has released a partial payment on the referenced claim. It is our position that
this claim has still not been reimbursed correctly and that additional benefits are due.
Please be advised, it is our position that contractual provisions stipulate a higher level of payment for this treatment. As a
participating provider, we feel the following contractual language or fee schedule reference is applicable to this claim and
justifies additional payment:
{Insert potentially applicable contractual language. Reference the page number or attach copy from contract to add as an
attachment to appeal.}
Our review of the provider contract does not reveal any language justifying the current level of payment. In order to assess
the accuracy of payment, we request your response regarding how the payment was calculated ,and what portion of the
fee schedule was utilized. It is our position that if terms of the contract are in direct conflict, the higher reimbursement
should be allowed. As you are likely aware, many courts have ruled that managed care contracts are contracts of adhesion
and that the organization responsible for drafting the contract wording can be responsible for unclear and ambiguous
terms.
Based on this information, we ask that this claim be reviewed. We appreciate your prompt attention to this matter.
Sincerely,
Appeals Specialist
Summary and Training Opportunities
What We’ve Learned Today and Steps for the Future
Training Opportunities
Always educate the patient and take
the stance of patient-friendliness
 Have the patient fill out Assignment
of Benefits forms in liability
scenarios
 ICD-10 training includes location of
injuries, which will help ID Auto and
Work Comp accidents
 Keep a paperless “paper trail” by
notating every detail of the claim
cycle. Every detail helps.


Terms to
Remember:
◦
◦
◦
◦
◦
Tort
Adjuster
Adjudication
Lien
Utilization
Review
◦ Silent PPO
◦ Appeal