Program Materials. We Want Our Money: 10 Strategies for Effective Collections When the Patient and Payer Won t Pay

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1 Program Materials We Want Our Money: 10 Strategies for Effective Collections When the Patient and Payer Won t Pay Copyright , PWW Media, Inc. All Rights Reserved. All Use Subject to Attendee License Agreement.

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3 abc360 Revenue Cycle Management Sessions WE WANT OUR MONEY: TEN STRATEGIES FOR EFFECTIVE COLLECTIONS WHEN THE PATIENT AND PAYER WON T PAY Overview When the patient won t give you the insurance payment Collection strategies for patient-owed amounts Collection strategies for denied claims Collection Strategy #1: Utilize Effective Payer Appeal Strategies 1 st Identify For each denied claim, examine why If the problem is your error, correct and resubmit the claim Review documentation to see if another diagnosis code was substantiated, but wasn t on the claim Avoid resubmitting claims without any alterations 2 nd -Act Set a goal of submitting appeals within 7 days of receiving a denial Helps avoid risks of missing timely filing deadline Page 1

4 3 rd Investigate An effective appeal is more than blindly resubmitting the claim Make an argument backed by evidence Examine rationale for denial Make a list of reasons why the denial was incorrect Do some detective work: Read patient s medical record Review insurer s provider manual Follow-up on diagnosis and treatment Speak with the providers on the call 4 th Respond Some denials can be reversed based on a phone call It is best to put your argument in writing Be sure to request review by someone familiar with ambulance claims Known as a peer-to-peer review If appeal is denied, can allow additional grounds for appeal Research the rules for appeals at that insurer If a particular form is required use it Most have designated addresses use the correct one Page 2

5 Research the Rules for Appeals Most insurers have multi-level appeals processes Understand the insurer s appeals process Don t be afraid to appeal denials to a higher level 5 th Incorporate Evidence Don t just state your opinion Use supportive references to objective sources Supportive References Medicare Manuals Relevant Guidance Documents Contract with Insurer Insurer s published policies Insurer s website Refuting Medical Necessity Denials Consider having the patient s physician write a short description on why the patient required an ambulance Why other means of transportation were contraindicated 6 th Don t forget! Set a reminder to follow-up in 30 days Make sure appeal was received 7 th Keep a log For each denial, log: Amount Reason Date of Service/Denial Page 3

6 Keep a log of results Do you see trends? How effective are your appeals? If you notice that an insurer is consistently denying certain services This may indicate a problem: With internal systems Coding practices Collection Strategy #2: Patients Keeping Insurance $ File a Complaint With the Patient s Insurer Let the insurer know Utilize the insurance company complaint/fraud procedures Why Fraud Procedures? If the patient is keeping the insurance money, perhaps the request for ambulance services was simply a sham for the patient to get money This is a potential marker for insurance fraud Filing Complaints with Insurers Important to alert insurance companies which of their insureds are keeping the money Insurance fraud is a big concern for insurance companies Page 4

7 State Department of Insurance Some states have a mechanism for providers to file a complaints State Department of Insurance may also be interested in investigating patients who engage in insurance fraud Collection Strategy #3: File a Report With Local Law Enforcement Local Law Enforcement When patients get paid but don t pay you, consider filing a criminal complaint Charges we ve seen in these cases include: Theft of Services Theft by Deception Theft by Failure to Make Required Disposition of Funds Received Theft by Unlawful Taking or Disposition Criminal Charges Whether this constitutes a crime and will vary by state Here are examples from one state Theft by Failure to Make Required Disposition of Funds Received A person who obtains property upon agreement or subject to a known legal obligation... is guilty of theft if he... fails to make the required payment or disposition 18 Pa.C.S Theft by Unlawful Taking or Disposition A person is guilty of theft if he unlawfully takes, or exercises control over, moveable property of another with intent to deprive him thereof 18 Pa.C.S Page 5

8 Theft by Deception A person is guilty of theft if he intentionally obtains or withhold property of another by deception 18 Pa.C.S Theft of Services A person is guilty of theft if he intentionally obtains services for himself or another which he knows are available only for compensation, by deception... by a false token or other trick or artifice to avoid payment for the service 18 Pa.C.S Collection Strategy #4: Use Data and Services From Credit Bureaus Skip Tracing Available from credit reporting companies, such as Experian and Trans Union Verifies phone numbers and addresses Scoring Models and Analytical Services Helps determine which accounts to collect How and when to contact How to allocate resources Maximizes Collectible Dollars Summary of credit and non-credit data Collect more efficiently Make profitable write-off decisions Page 6

9 Collection Strategy #5: Use Time-of-Service Payment Strategies Time of Service Payment Remember, the Ambulance Revenue Cycle is holistic Identifying non-covered services and patient cost-sharing obligations at the time of call intake affords you an opportunity to capture payment prior to the time of service Time of Service Payment Payment can be obtained at the time of call intake Or at the time of service Time of Service Payment This practice is only for nonemergencies Do not implement a time-of-service payment system for any emergency calls Is This Legal? Yes! Even Medicare s own ABN form says so Collection Strategy #6 Use The Right Language on Your Patient Signature Form Page 7

10 Signature Form Patient signature forms can be used as a written promise to pay in collection cases Some small claims court judges rely on this language to find in favor of the ambulance service Signature Form Of course this won t guarantee payment But it can be one more tool in the toolbox Collection Strategy #7: Use Recurring Payments Recurring Payments Great for frequent fliers Collect credit card information prior to the time of transport Agree on an amount and auto-deduct that amount on the date of the transport Recurring Payments Can be done by: Credit card PayPal E-Checks Page 8

11 Collection Strategy #8: Shore Up Facility Contracts Shore Up Facility Contracts Review and update your facility agreements with Revamp the provisions in facility financial responsibility Shore Up Facility Contracts Facilities responsible for: All transports under Medicare Part A Ensure your contract clearly spells out which trips are under PPS Can also negotiate facility responsibility for other types of services Shore Up Facility Contracts If the Facility is notorious for calling you for non-transport and non-billable calls, consider using a retainer-style system Collection Strategy #9: Improve Financial Hardship Process Financial Hardship Don t rule out true financial hardships Important to have good financial hardship policies Page 9

12 Financial Hardship Utilize your own financial hardship form and information gathering for your patients But, you can also utilize information from hospitals and other facilities Did it approve a financial hardship for the patient? Financial Hardship Remember to ask this: How long will it take you to pay? Not this: How much can you afford to pay? Collection Strategy #10: Consider Suing the Patient Using the Legal System Collection agencies can be effective for certain types of debt But, if a patient keeps the insurance payment, consider using the legal system instead Benefits of Suing the Patient Can obtain a court judgment that can be enforced Will eventually enable you to get a lien or even seize assets (in some states) But, there are some down sides from the public relations point of view Before Filing Suit Send a demand letter Include your contact information Make a clear demand to pay by a certain date or legal action will begin Page 10

13 Don t Always Need an Attorney Small claims courts are almost always available Attorneys are not typically required in small claims courts Small Claims Court How small is a small claim? Varies from state to state Usual range is claims under $5,000 - $10,000 Check your state law Where to File Claim? Jurisdiction will always lie in the area where the patient lives Can possibly have jurisdiction where the station is or where services were rendered This could give you home court advantage Bottom Line Modernize and adapt collections to current technology Per persistent, don t give up tenacity usually pays off Bottom Line Focus efforts on accounts where success is more likely Consider multiple approaches and don t be afraid to try new things but make sure all laws are followed (FDCA, FCRA, etc.) Page 11