2017 Spring Convention

Transcription

1 2017 Spring Convention Massachusetts Auto Billing Two Paul Andrews

2 Please scan IN at the start of class Please scan OUT at the end of class You must attend the entire session to earn your credit(s) for this class

3 Once $2K PIP Exhausts Ask yourself 3 Is Medical Payments Coverage available? What health coverage does the patient have? If the patient wasn t in their own car, does the patient have Med Pay coverage of their own? Are chiropractic benefits available by the health insurance? Is the Health Plan Fully Self-Funded? Even if there is no Chiro Coverage, bill health insurance Then COB the EOBs to Auto showing no chiropractic coverage exists. Are we in or out of network with the patient s health carrier? Why do I need to ask myself these questions?

4 PIP Coverage Limits 4 PIP coverage limit is $8, Just because PIP adjusters close their file doesn t mean you do! Remember after the initial $2,000 in PIP benefits exhaust that there is potentially still $6,000 in PIP as well as possibly Med Pay applicable* *sans an IME/IRR cut off

5 No health or government program 5 PIP benefits would continue after the initial $2, exhaustion when no health coverage exists and then Medical Payments coverage if available. PIP benefits & any available Med Pay would continue after the initial $2, exhaustion when a patient has a government program like Medicare, Mass Health, Tri-care, VA Choice, Medicare Railroad, etc.

6 Medicare s Policy on COB 6 Medicare Secondary Payer (MSP) Manual 60 - No-Fault Insurance (Rev. 49, Issued: ; Effective/Implementation: ) Under 1862(b)(2) of the Act, (42 U.S.C. 1395y(b)(1)), Medicare does not make payment for covered items or services to the extent that payment has been made, or can reasonably be expected to be made under no-fault insurance. Medicare is secondary to no-fault insurance even if State law or a private contract of insurance stipulates that its benefits are secondary to Medicare benefits or otherwise limits its payments to Medicare beneficiaries. Emphasis added

7 Medicare s Policy on COB 7 Medicare Secondary Payer (MSP) Manual 60 - No-Fault Insurance (Rev. 49, Issued: ; Effective/Implementation: ) If services are covered under no-fault insurance, that insurance must be billed first Medicare can pay for services related to an accident if benefits are not available under the individual's nofault insurance coverage because that insurance has paid maximum benefits The question in each case involving accident-related medical expenses is whether no-fault benefits can be paid for these particular services. If so, the no-fault insurance is primary. Primary Medicare benefits cannot be paid merely because the beneficiary wants to save insurance benefits to pay for future services or for non-covered medical services or non-medical services. Since no-fault insurance benefits would be available in that situation, they must be used before Medicare can be billed. Emphasis added

8 Medicare s Policy on COB 8 Medicare Secondary Payer (MSP) Manual No-Fault Insurance (Rev. 34, Issued: ; Effective/Implementation Dates: ) Medicare is secondary to any no-fault insurance, including all forms of automobile no-fault insurance, automobile medical payments, and non-automobile no-fault insurance. (See chapter 2, 60.) No-fault insurance is a form of insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy, or operation of an automobile regardless of who may have been responsible for causing the accident. MedPay is a form of no-fault insurance even when included in automobile insurance of any type. Payment may not be made under Medicare for otherwise covered items or services to the extent that payment has been made, or can reasonably be expected to be made, for the items or services under no-fault insurance. A conditional Medicare payment may be made if the no-fault insurance has not paid and cannot reasonably be expected to make payment promptly. Emphasis added

9 Mass Health on COB 9 Pursuant to 130 CMR All resources available to a member, including but not limited to all health and casualty insurance, must be coordinated and applied to the cost of medical services... all providers must make diligent efforts to obtain payment first from other resources, including personal injury protection (PIP) payments, so that the Division will be the payer of last resort Emphasis added

10 Fully Self-Funded ERISA plans Self-Funded insurance plans / Welfare funds and some others fall under E.R.I.S.A. (E)MPLOYERS (R)ETIREMENT (I)NSURANCE (S)ECURITY (A)CT Form 5500 may be obtained from websites like: How do you find out if a plan is an ERISA plan? -Ask when verifying coverage. If it is an ERISA plan, ask for an ERISA statement so your office can send it to the PIP carrier Some Carriers have a pay and pursue policy and you may be stuck with contract rates If ERISA (fully self-funded) PIP continues to the full $8,000 in total coverage and all Med Pay if applicable* *sans an IME/IRR cut off 10

11 Health Insurance Correlation after the PIP $2,000 exhaust 11 Health Insurance that is not FULLY Self-Funded is available then bill the Health Insurance Carrier. Attach a $2K exhaust letter to each paper claim. PIP still responsible for co-pays, co-insurance, deductible and/or any other patient responsibilities not under contractual obligation with provider to write off Utilize a Non-Covered Service Waiver Form if you are providing services that the patient would be responsible for paying when not covered by their insurance.

12 12 After the health insurance carrier processes the claims and sends out the explanation of benefits. If your provider and/or group is in contract with that insurance company you cannot bill back to the PIP carrier any amount except the patient s responsibility as it appears on that EOB. If there is no contract then you may bill the amount not covered even if there are usual & customary (U/C) reductions. Consider opting out of PPO/Discount contracts and/or their WC/Auto portions of the contracts

13 Case Law 13 n. noun 1. The law as established by decisions of courts, especially appellate courts in published opinions

14 Dominguez v. 14 Liberty Mutual Insurance Co. What it says What it does not say What to do when it is a problem Summary: You must follow the health insurance plan provisions and restrictions. e.g. obtain authorization for visits if required

15 Dominguez v. 15 Liberty Mutual Insurance Co. Recommendation Inform patient upfront if your office is out of network and as a result the chiropractic benefits are not available in your office If your office is out of network and there is no coverage under their plan for out of network services. The patient should sign something in writing that outlines that you have told them this and they still choose to receive care in your office. (If there is Med Pay coverage, all is not lost for reimbursement) Send that document to the patient s attorney with the lien

16 Mejia, et al. v. American Casualty Company 16 Appeals court decision on Medical Payments coverage (6) We note that, unlike PIP, MEDPAY is an optional coverage, the terms of which are not prescribed by statute. Thus, the coordination of benefits provisions in G. L. c. 90, 34A, that were construed in the Dominguez case do not apply to MEDPAY coverage. MEDPAY provides a meaningful optional benefit for some consumers because it covers treatment which would not otherwise be covered by health insurance or PIP.

17 How to bill when: You are out of network The patient s plan does not have out of network coverage (but has in network coverage) There is Med Pay available Bill the Auto Carrier - $2K Exhaust Letter is received 2. Bill the Health Carrier Receive the EOBs stating no O.O.N. coverage 3. Bill the Auto Carrier back COB the EOBs to the PIP carrier 4. PIP denial letter for Dominguez v. Liberty Mutual 5. You send letter back requesting payment from Medical Payment coverage pursuant to Mejia, et al. v. American Causality Co.

18 Medical Payments Coverage Contractual Requirements by the member (patient) 18 MetLife v. BCBS of MA 4. Conclusion. Because we find nothing in the statutory language governing PIP or MedPay to prohibit health insurers from deferring coverage due to the existence of MedPay benefits, we affirm the order of the Superior Court judge granting summary judgment in favor of the defendant Blue Cross.

19 MetLife v. BCBS of MA 19 If the patient has a health insurance carrier that states in the member contracts the requirement to exhaust Medical Payments coverage first, then this opens the Medical Payments Coverage. You still need to bill the health insurance carrier. A letter from the carrier stating their contractual language may suffice but bills may still need to go the carrier for their response to the claims. Some carriers provide a Med Pay Letter. Some provide an EOB denial stating the Medical Payments must be exhausted.

20 Remember Mejia, et al. v. American Casualty Company 20 This Case Law obligates you to bill the health insurance carrier to have claims processed. Even when you know that the claims will deny for: No Chiropractic Coverage at all No Out of Network Chiropractic Coverage Full $8,000 in PIP and/or available Medical Payments coverage must be exhausted first. Government Program coverage like Medicare and Mass Health. Provide copies of the patient s health cards to show proof of coverage type. Billing to a government health carrier is not required Initial Billing Packet should include this information Supplying the Medicare / Mass Health billing restrictions documentation may be necessary (reviewed in session 2)

21 PIP Benefits Denials 21 No PIP Application denial for non-cooperation As long as all the information needed to process a claim is received by the PIP carrier simply denying benefits because a specific form such as a PIP application has not been filled out may not be a valid reason for a denial. Your office paperwork usually has most of what is on a PIP application. Review a PIP Application Include in your paperwork all information that may appear in a PIP application Including wage/salary release, Medical Records Release for PIP Carrier

22 PIP Benefits Denials 22 Non Cooperation Patient not providing details about the accident (non responsive to the PIP Carriers inquires/requests Patient refusing to attend an IME Patient continually no shows an IME Chapter 90 Section 34A Exclusions Work Comp Drugs / alcohol Fleeing Intentional damage / harm

23 PIP Benefits Denials 23 Independent Records Review (IRR) Must be performed by a Like Practitioner. Retro denials can be challenged and should be! Rebuttal to any portions of the report that the attending Chiropractor does not agree with should be written and sent to the PIP carrier and copied to the patient s attorney include in the rebuttal any records you may believe the review did not have at the time of their review. Independent Medical Exam (IME) Need NOT be performed by a Like Practitioner. (Ortiz v Examworks) Retro denials can be challenged and should be! Make sure all the records go with the patient to the appointment. Rebuttal to any portions of the Exam report that the attending Chiropractor does not agree with should be written and sent to the PIP carrier and copied to the patient s attorney. (Duffy v Amica)

24 Pedestrian struck by motor vehicle 24 The vehicle that struck the pedestrian is the PIP and the B.I. Carrier Claim would run just like any other PIP claim If a hit and run, look to the patient s own Auto policy or household Auto policy for coverage If none, look to MGL Chapter 90 Section 34N Assigned Claims Plan The patient may need to seek an attorneys assistance and/or at the MA Insurance Commissioner s office

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26 Please scan OUT as you leave If you are staying in this classroom for the next session you must have your badge scanned OUT for this session and scanned IN for the next session Thank you! Mark & Paul

27 27 Disclaimer TOP Education & the instructors acting on behalf of TOP Education are here this weekend to educate. They are not representatives nor speak on the behalf of any Insurance Company or TOP Education, LLC. Any discussion of a specific Insurance Company is for examples purposes only. All carrier specific policy or procedure questions should be directed to that carrier