Presented by: Lorrie Wood

May 15, 2014

Accelerating payments by increasing patient

compliance through education and advocacy

Doing Everything Right

• Pre-Registration• Insurance Verification• Pre-Certification• Financial Clearance• Charges• Coding• Timely Claim Submission

Denials Happen

Patients

Family Members/ Caregivers

EmployeesPayers

Third Party Review

companies

Technology/Lack of Technology

DENIALS

“Patient Denials”

• Up to 40% of denied claims are contributed to “patient” denials- “information needed from member”.

• Patient denials are not routinely tracked or classified.

• Many accounts moved to self pay.

Information Requested from

Patient

• Coordination of Benefits

• Pre-Existing Condition

• Add Newborn• PCP

designation/update• Medicare CWF Error

• Certificate of Credible Coverage

• First Report of Injury• Accident Form• Medical records

from other providers

Pre-Existing

• Pre-existing condition is no longer basis for denial however there are some “grandfather” plans– Payer denies claim for pre-existing condition

– Payer is requesting information for possible pre-existing condition exclusion

– Payer is requesting records from another provider

Pre-Existing

– The HIPAA checklist:• What is the effective date of coverage?

• What is the length of the lookback period?

• What is the length of the exclusion/waiting period?

• Will the payer accept prior creditable coverage?

Pre-Existing• Certificate of Creditable Coverage: A document that shows your prior

periods of coverage in a health plan. It is provided by the group health plan.

• If the document cannot be obtained, prior creditable coverage can be shown with any of the following documents accepted as evidence:

• Pay stubs that reflect a deduction for health coverage premiums• Copies of premium payments or other documents showing evidence of

coverage• Explanation of Benefits (EOB) forms• Verification by a doctor or the former health plan.• Review for Medicaid/Armed Services/OTHER

Pre-Existing

• Magic Number = 63 days• Check system for prior coverage• Contact primary care physician• Fully explain required information needed• Enlist assistance of patient’s employer• Requirements for securing COCC

Coordination of Benefits

• Currently Largest Volume of “patient” denials• Increase in COB requests with new ACA plans• COB requests for accident coded claims• Increase in frequency of COB updates

Steps to resolution

• Document all eligibility verifications• Provide patient with all information required to

update COB with all correspondence- phone numbers, information needed.

• Provide 3- way calls to payer• Always follow up with payer to check if

information has been updated• Request ALL claims pended to be released

MVA/Accident Details

• Automatic denial when E code is present– Review claim to ensure accident coding is present– Request copy of form or questionnaire – Request additional copy of form to be sent to

patient– Request if medical records can be submitted in

lieu of form

CWF Updates

• 40 million Medicare recipients, and that number is expected to be around 80 million in 20 years. With the first baby boomer hitting 65 in January 2011 we are experiencing a higher rate than ever of people joining the Medicare roles. In addition with the increase in disability claims there are a large number of new recipients under the age of 65.

• A common working file (CWF) is a tool used by the Centers for Medicare & Medicaid Services (CMS) to maintain national Medicare records for individual beneficiaries enrolled in the program. The system is used to determine the eligibility of patients and to monitor the appropriate usage of Medicare benefits.

CWF Updates

• A multitude of issues can prevent a claim from processing based on CWF information. Some of the most typical issues are

– Other health insurance primary over Medicare– Open third party liability claim– Incorrect date of death– Incorrect date of birth– Incorrect residency/citizenship– Incarcerated release dates

Steps to Resolution

• Confirm basis for patient’s eligibility with Medicare and review MSP rules.

• Educate all team members on MSP form and rules.• Contact all payers to confirm priority listed by each payer• Outline steps for patient to update CWF, including the

phone number the patient should call (800) 999-1118, retirement dates, payer name and termination date of conflicting payer

• Facilitate telephone conference call with patient to Medicare.

Case Study

Actual Case• BCBS pended claim for

accident and injury details from the patient, but patient would not return the accident form to BCBS. Hospital made several attempts to reach patient by phone and mail, but patient remained uncooperative.

Resolution• A subsequent review of the

medical records and determined patient was treated for an ovarian cyst, submitted appeal with clinical documentation, and BCBS paid claim.The patient had had a prior MVA that set an accident form flag, but this case was not associated with the MVA. Payment was secured including prompt pay penalty since claim denied in error.

Case Study

Actual Case• Insurer pended claim for

pre-existing condition investigation. Hospital continued down path to secure pre-existing questionnaire from patient and prior physician medical records.

Resolution• Contact with patient

identified prior coverage with no break in coverage. Secured COCC from previous employer and submits to payer.

• Insurer issues payment within 20 days.

Case Study

Actual Case• Medicare denied claim for

MVA coverage. Several calls to patient were unsuccessful. Letters were returned claim for patient was over 250K.

Resolution• Reviewed medical record and determined

patient had been discharged to nursing home. Contacted nursing home and secured next of kin information. Spoke with daughter who stated no claims had been paid. Assisted patient with POA process. Secured POA and completed 3 way call with Medicare contractor. Medicare stated they needed letter of exhaustion. Submitted letter of exhaustion- claim still denied. Contacted Medicare and they stated they needed full legend of all claims that were paid by auto coverage. Secured payment log from State Farm and submitted to Medicare. CWF conflict was resolved and claims released for payment.

Additional Tips

• Speak to patient at point of service about their obligation to supply information to their carrier

• Plans with effective dates less than 6 months should indicate a “red flag” for COB

• Inquire to “length of employment”• Contact patient as a “patient advocate”

Additional Tips

• Re-think certified mail, utilize “overnight” communications for high dollar accounts

• Provide the patient with all information required for updates i.e. phone numbers, fax numbers, websites, forms, contact names.

• Continue to follow up with payer• Identify payer requirements and create

provide COB forms/accident forms (TRICARE)

Additional Tips

• Contact employer HR departments for assistance

• Base efforts on dollar values• Utilize three way calls and after hour contacts

(possibly utilize other departments)• Consider home visits• Create review process prior to bad debt

Questions

• Lorrie Alvey-Wood, Vice-President RSource lwood@rsource.com

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