Provider Best Practices

for Complex Liability Claims

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Date: 2013-12-27 12:59+05:30
Content
Overview
Industry Dynamics
Action steps to take beginning at the point of registration on
employment injury claims
The impact of state and federal laws
Why facilities and providers may not be maximizing recoveries on
liability claims
Training opportunities for liability claim handling
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Overview
Liability claim processing boils down to the following elements:
Training up-front data acquisition staff
Classifying accounts correctly upon point of service
Identifying administrative inefficiencies with insurance claim handling practices that
create financial loss
Garnering insurance details of each injury encounter
Using forensic analysis in an administrative way to resolve open claims for
injured patient
Working with patients, next-of-kin, employers, insurance companies, and
attorneys to take a medical claim and do all the legwork to get it paid by
a liability-based insurer
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Industry Dynamics
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Industry Conditions
High Self-Pay = Growing Trend for Facilities
Self-pay and bad debt are often difficult classifications hospitals genuinely
want to avoid these areas. They often become default zones for patients who
present with no coverage at time of encounter.
Hospitals often have multiple collections vendors on board with only an
8-25% rate of return (high-end estimate).
Self-pay percentages of overall revenue should not go beyond 20% of
overall hospital A/R, but often does
Increased education of liability claim handling assists facilities
across the board
5
State Negligence Rules: Motor Vehicle Accidents
No-Fault States: Advantages
Personal Injury Protection provision
exists on policies, in addition to
MedPay provision as purchased by
motorists
Florida, Hawaii
Kansas, Kentucky
Massachusetts, Michigan
Minnesota, North Dakota
New Jersey, New York
Pennsylvania
Utah
Tort States: Advantages
Comprises the remainder of the country
aside from true no-fault states
Individual must be found at fault in
an accident = multiple avenues of
insurability (either patients own policy,
or at-fault policy, with insurance
subrogation to occur behind the
scenes.)
More investigation; more coordination;
but with skilled follow-up, the
hospital can achieve strong
returns.


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Overall Conditions for WC Policies
Reimbursement Rates
Each state WC Board determines
reimbursement rates
Outpatient Fee Schedules are
around 60-65% reimbursement
nationally
Inpatient payment structures are
often reasonable and achievable --
with appeals and close follow-up
between hospital and payer
Escalating to the state WC Board
works to the hospitals advantage
Timeliness rules vary state to state
Employment Rates
Researching top employers and safety
statistics in each region is helpful to
understand local WC demographics and
patterns
Employability is a big factor; for example,
Florida may have more MVAs than
Workers Comp. However, large
employers in FL will very often have more
WC accidents:
Wal-Mart
Publix Grocery
Home Depot
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Macroeconomic Environment
United States Injury/
Fatality Rate
Total uninsured: 16.7% = 50.7 mm
people
MVA injuries: 2.22 mm injuries (2011)
MVA fatalities: 32,367 (2011)
WC injuries: 2.9 mm injuries (2011)
WC fatalities: 4,609 (2011)
Personal injuries
Dog bites: 800,000 med visits
Falls: 200,000 children
Falls: 2.3 mm older adults (2010)

Hospital Outlook
Reduced reimbursements: CMS
Expanded future coverage through PPACA
Aging population increasing
Declining birth rate; future generations
bearing increased CMS costs
Immigrant population showing trends of
declining birth rate
Commercial health payers increasing
deductibles and out-of-pocket expenses

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The Present and Future
9
Times Have Changed

Insurance companies want to know the thought processes physicians use to
reach medical decisions.

Payments for liability injuries, such as Workers Compensation injuries, are
rarely paid without medical justification.

Clinical documentation and well-completed forms can assist providers in
meeting complex insurance and state-driven 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 and policies.

Lifecycle of a Liability Claim
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1. Patient presents to physician with chief complaint
2. The collection of data for a medical claim begins at this
time during check-in
3. Frontline representatives collect and document
insurance information
4. The most important aspects of the medical claim cycle
occur between the time the patient arrives at the
provider and the time the medical claim is generated. It
can be the shortest part of the entire revenue lifecycle,
but also the most important.
Lifecycle of a Liability Claim
Note:
Many points
exist in the
cycle for a
claim to get
lost or go
awry.
5. During the patients evaluation, the physician is
responsible for documenting the details of the
encounter.

6. Coders assign numeric codes for chief complaint,
other diagnoses, external forces if applicable, and
procedures rendered. (Example: 847.0 for neck
sprain; E812.0 for motor vehicle accident that
may occur.) Note: MVAs may occur in the course
and scope of an individuals employment.

7. Billers identify payer, speak with claims adjuster,
and ship bill and records to correct address.
Lifecycle of a Medical Claim, Briefly
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.
Payer follow-up is critical to reimbursement
Receipt of claim and accompanying records
Adjudication
Payment determination
Exceptions escalated
Denials explained clearly and justified by payer
Lifecycle of a Medical Claim, continued
Best Practices
Overview on Claim Handling to Achieve Greater Performance

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Data elements to garner:
Employer name pertinent to injury
Employer address and main phone number
Date of Accident
Basic Injury, Body Part(s) affected
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
Do not default financial class to Self Pay

Registration:
On-the-Job Injuries
NOTE:
If insurance
carrier is known at
patient encounter,
call insurance
for service
authorization as
soon as possible
Data elements to garner:
Policyholder of vehicle
Role of patient (driver, passenger, cyclist,
pedestrian)
Patient address and main phone number
Date of Accident
Where/How injury occurred
Insurance company known?
Drivers auto insurance company name
Other partys auto insurance name
Own health insurance as secondary plan
Attorney data if applicable

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Registration: MVAs
Patient unable to communicate:
Gather data from next of kin as
appropriate
Request police report post-discharge
Place call/send questionnaire to
patients home for accident and
insurance details
Do not default financial class to Self
Pay
MVA: Secret Coverage to Obtain
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Registration:
Personal Injuries
Data elements to garner:
Geographic location of injury (address of
where injury occurred) - the key to liability is
if the injury occurred NOT at patients own
home; although sometimes there could be
liability propensity on leased property.
How injury occurred Examples: neighbors
pitbull bit patient, or slip/fall at grocery store
Patient address and main phone number
Owner/Entity Contact Data
Date of Accident
Health plan as secondary (Plan B option)
Attorney data if patient has hired
representation


Patient unable to communicate:
Gather data from next of kin as
appropriate
Request ambulance or police report (if
first responders were on the scene)
post-discharge
Place call/send questionnaire to
patients home for accident and
insurance details
Do not default financial class to Self
Pay

Tricky Examples
Shout Out Your Answers
Elderly woman suffers a herniated disc while lifting
a bag of soup cans at her church food pantry.
Liability or Medicare? Both? Neither?
A man riding a dune buggy flips over and suffers
a broken rib and collarbone.
Motor Vehicle or Health plan? Both? Neither?
A woman riding a motorcycle oversteers and grazes the side of her body, and
suffers road rash.
Motor Vehicle or Health plan? Both? Neither?
A man transferred from another facility has MS and old orthopedic injuries
from his job as a postal worker.
Workers Compensation or Health plan? Both? Neither?

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The Significance of Clinical Documentation
Substantiates services
Charges will be understood at the insurance
company
Validates necessity of treatment
Speeds up bill payment when packaged
together particularly for WC claims
Nurses notes
Physicians report
History and Physical
Lab reports
Radiology reports

* Denotes Where allowed by state/county law;
ensure signed authorization on file by patient
Tips:
1. Marry medical records with bills for WC claims 100%
of the time at first submission
2. Send liens, lien letters, or request Letters of
Protection to attorneys that request medical records to
ensure they are aware of medical charges in advance of
final settlements*
3. Issue your invoice for medical records where allowed
by state law and hospital policy
Therapy:
Physical
Behavioral
Speech
Durable Medical Equipment
Implantable Device Invoices
Itemization of all services rendered
At the Insurance Company
Behind the Curtain:
What Happens to the Bill Form and Records


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Electronic submission (secure 837-5010 format)
Mandated/encouraged states:
Texas
California
Minnesota
Illinois
New York
Dependent on payer capability
Some are set up to accept electronic submissions
Paper Submission
Red 1500s or UBs
Black and White forms acceptable; sometimes rejected for
readability ensure legibility
Fax Directly to Insurance Adjuster
Note:
Always indicate
in your host
system the
submission date
and location of
where the bill
and records were
sent. This
includes the
specific
adjusters name.
Work Comp Claim Submission Methods
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
Employer must file accident report.
Sometimes data centers are within the US or off-shored
It is not customary to contact data centers directly for claim status
Insurance Company Data Centers
Critical tips:

1. Having claim
numbers on
documents before
mailing saves an
average of 21 days of
processing at the
insurance company
(really!)
2. If no claim number
was opened or found,
claim will be rejected
as such.
.

Medical bills (claim forms)
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.
Data Centers, continued
Example UB
Resulting EOB with errors
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
Adjudication
Managed Care departments exist
in the Property/Casualty
insurance environment!
Line-by-line re-pricing of bills
occurs using various methods
PPO contracts
Fee schedule
Usual and Customary
guidelines
Nurse case management
DRG (not line-by-line
analysis; rather a fixed
code)
Many other methodologies

A Few Words on Silent PPOs
When a claim is paid, an
Explanation of Benefits (EOB)
is issued with the check
The rationale of payment
should indicate if a contractual
agreement was accessed for
discounts
Does your facility have a
contract in place with the
payer mentioned on the EOB?
Challenge the insurer if not!
Bill Review and Pricing
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
Medical decision making must
be clear in documentation
Utilization Review
Reimbursement Methods
How a Claim is Paid (or Not)



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Types of Reimbursement: National Overview
APCs
Capitation
Case rate
DRG
Day Differentials
Service Differentials
Fee Schedule and
Timely Pay Fee
Schedules
All methodologies
operate under
various contracts,
policies, and
guidelines, that all
depend on state
and federal laws.
Flat Rate
Per Diem
Managed Care stop loss
outliers
Case based outliers
Reinsurance stop loss
Percentage stop loss
At Charges
Sliding scale
discounts
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. Its 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
Courtesy: Marilyn Fordney; Medical Administrative Procedures
Breaking the Methodologies Down
Ambulatory Payment Classifications (APCs): 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
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
Managed Care stop loss outliers:
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 dont 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.


Breaking the Methodologies Down
A percentile is defined as a value
on a scale of 100 that indicates
the percent of a distribution that is
equal to or below it. For example,
the 75th percentile means that 75
percent of all fees for CPT code
99203 fall at or below $136. It also
means that 25 percent of all fees
for CPT code 99203 fall at or
above $136. Data is analyzed
by ZIP code by the
insurer.
99203 = $136 by XYZ Insurer
Office or other outpatient visit for
the evaluation and management
of a new patient, which requires
these three key components: a
detailed history; a detailed
examination; and medical decision
making of low complexity.
Physicians typically spend 30
minutes face-to-face with the
patient and/or family.
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Usual and Customary Explanation
Workers Compensation Details
Analyzing the Process



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Workers in the late 1800s had it tough. For injuries and deaths, the legal processes were
uncertain. Negligence had to be proven by the employee, and very often there was little
recourse.
In 1911, the first workers compensation laws were adopted by several states. The laws allowed
injured workers to receive medical care without first taking employers to court.
All states currently have workers compensation laws. They vary from state to state.
This coverage is the most important coverage written to insure workplace accidents.
A Very, Very Brief History
Two types of coverage:
Federal compensation laws paid by US Department of Labor
Applies to miners, maritime workers, postal workers, and
government workers
State compensation laws paid by self-insured businesses, insured
employers, or state insurance funds
State and private business employees

Types of Coverage
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-day payment timeline. Employers may violate this there are no
penalties for violation. Courteous but aggressive pursuit is a must.
Self-Insured Employers
The Beginnings of
Workers 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.
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.
What Workers Compensation Reform Did
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
More Reform Measures
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 employers 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.


The Process In Brief
Out-of-State Claims
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:
Note:
Maritime employees
do not fall under state
workers compensation
laws. Example: Cruise ship
employees injured at sea
often have their medical
bills paid in full, or
negotiated with a maritime
company that works with
the cruise line.
.
Alabama
Alaska
Arkansas
New Jersey
North Dakota
Ohio
Washington
West Virginia
Wisconsin
Billing Problems
Solutions to Common Issues,
and Avoiding Underpayments and Denials


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Billing Problems
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 patients 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
Gender error
Missing principal diagnosis code
Missing revenue codes on UB
Missing CPTs on 1500 or outpatient UB
Missing Physician name and ID
Type of bill third digit (billing sequence)
doesnt correspond to statement coverage
dates
Correct gender
Add diagnosis
Add revenue codes
Add CPTs
Add Physician name
Correct Type of Bill to correspond
with dates
Note: Resubmit corrected claims
with new Type of Bill
Billing Problems
Number of hospital days for room
charges must match number of
inpatient days
Missing units many times defaulted
to 1 at insurance company if missing
on claim!
Always match inpatient days
Add value codes wherever applicable
Always, always input units. Insurance
companies pay by units. Anesthesia is
paid by minutes. (Surgical time is
examined.)
Billing Problems
Undocumented workers
Incarcerated individuals
Municipal workers
Burn liability claims
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

Unique Situations
Coordination of Benefits
Whos on First, Second, Third



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All Workers Compensation plans are
inherently no-fault
The injured worker is not responsible for
payments
The workers compensation carrier that
insures the employer will absorb liability and
pay
If the employer is self-insured, they will pay
Workers Compensation COB
Note:
ONLY if a claim
ultimately ends up
NOT being a true
workers compensation
situation, then it will
be: A health plan
responsibility, or
A self-pay claim, if no
health plan is active
Sometimes, a patient will opt out of the Workers 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
Workers Compensation Tort Cases
Motor Vehicle COB
In a No-Fault state, COB looks like
this:
PIP (Personal Injury Protection)
pays first
Patients health plan pays
second
At-fault third party pays third
Co-pays and deductibles can
kick into patients MedPay if
funds are available
At-fault settlement reimburses
health plans; satisfies
outstanding provider residuals



In a Tort state, COB looks like this:
- Patients MedPay pays first OR
at-fault Bodily Injury plan can
also be pursued
- Patients health plan pays second
- At-fault settlement reimburses
health plans; satisfies
outstanding provider
residuals
55
Note: Governmental payers are the payers
of last resort
Note: Double check your health contracts
for any specific COB language with lien
filing and liability settlement pursuit
Challenging Insurers
Maximizing Reimbursement and Speeding up Payments



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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 dont get
anywhere
Delinquent or Slow Pay Claims
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.
Payer Response
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 & Training Opportunities
What Weve Learned Today and Steps for the Future
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Always educate the patient and take the stance of
patient-friendliness
Have the patient fill out Assignment of Benefits
forms consistently
Basic coding training includes locale (industrial
premises; highway) of injuries, which will help
identify accidents
Keep a paperless paper trail by notating every
detail of the claim cycle. Every detail helps.

Terms to Remember:
Adjuster
Adjudication
Utilization Review
Silent PPO
Appeal

Training Opportunities
Feedback
Claudine Nesheiwat
Director of Operations, Liability Services
Phone: 804-272-6001 x227
E-mail: cnesheiwat@apallc.com