Setting Up or Fine Tuning a TPL Program at Your Facility

Transcription

1 Setting Up or Fine Tuning a TPL Program at Your Facility By Jennifer M. Powers, Esq. David H. Moon, Esq.

2 Presenters Jennifer Powers is a Partner at Powers & Moon, LLC, a law firm representing health care providers in patient accounts recoveries. Jen graduated with distinction from the University of Iowa College of Law, and has focused her practice on collections and creditor s rights since 1995, with an emphasis on healthcare reimbursement since She has successfully resolved thousands of third party liability accounts on behalf of providers. Jen has also worked with providers nationwide, educating them on such other issues as Silent PPO access, improper discounts, denials and delays. David Moon is a Partner at Powers & Moon, LLC, and he has focused his practice on representation of health care providers in patient account recoveries since David is a graduate of the DePaul University College of Law, and has successfully resolved numerous contentious matters for his hospital clients, including thousands of third party liability accounts and the litigation of hundreds of Lien Adjudications in circuit court. A member of the Federal Trial Bar, he has also supervised litigation in other states and jurisdictions. 2

3 Provider Panel Members Gary Breuer, Alexian Brothers Health System: Gary is the Vice President of Revenue Cycle and Best Practices at Alexian Brothers Health System. He has twenty two years of healthcare and revenue cycle operations experience. Gary has been at Alexian Brothers Health System the last nine years. He implemented a combined Patient Financial Services office to serve all hospitals and employed physicians. Days in A/R were reduced from 65 to 40. Gary recently managed a comprehensive Revenue Cycle improvement project which generated $35 million in annual recurring benefits for Alexian and represented a 5% lift to net revenue. Gary also co-lead Alexian's $23 million software system replacement project to implement Meditech throughout all the hospitals. Previously, Gary was a Senior Manager in Healthcare Consulting at Arthur Andersen, and then at BearingPoint, focusing on revenue cycle operations and system installation projects for a wide variety of healthcare, government and consumer products clients. Gary has a B.S. in Accounting from the University of Illinois and a MBA from Northwestern Kellogg School of Management. 3

4 Provider Panel Members (cont.) Laura Pomis, Alexian Brothers Health System: Laura is the interim Director of Patient Financial Services at Alexian Brothers Health System. She has over twenty-five years of healthcare experience in finance, information systems and revenue cycle operations. Laura has been at Alexian Brothers the past six years. Previously she held a variety of positions with Caremark, Creative Business Technology, Endoxy Healthcare, and Concuity. Laura has a B.A. in Business from Carroll University. 4

5 Course Objectives Learn how to formulate a global game plan for identifying potential third party liability (TPL) accounts and for initiating, or fine-tuning, a TPL program. Learn how to spot TPL patients as they enter your facility and to bucket their accounts for proper TPL follow up. How to train your staff on practical techniques to quickly and effectively gather TPL information to get accounts paid by a TPL payer. How to track the dollars involved, and learn how to compare recoveries under your new TPL program to recoveries for the same types of accounts prior to your new program. Learn how to comply with the Illinois Health Care Services Lien Act in running your TPL program. Learn how to calculate the lien act amount, for use in negotiating with attorneys. 5

6 Disclaimer The information provided in these materials and during this presentation is for informational purposes only, and does not constitute legal advice. The information contained herein is not offered as and does not constitute legal advice or legal opinions. You should not act or rely on any information contained in these materials or this presentation without first seeking the advice of an attorney. 6

7 Scope of the Endeavor Strategic Planning Who needs to be involved? What accounts are impacted? (20% of all injury-related emergency department visits are from motor vehicle accidents) Billing issues: governmental payers, health insurance considerations, timely filing issues, establishing a policy. 7

8 Identifying the Relevant Accounts Begin by selecting diagnosis codes to carve out for review, followed by EMR review for confirmation. Accounts identified by the patient. Accounts identified by the insurer. Other registration information. 8

9 Let the Fact-Finding Begin! I feel the need, the need for speed! 9

10 Fact Finding (continued) WHAT happened? In what capacity was your patient involved? A driver? A passenger? Probably at fault? Probably not at fault? Slip and fall? WHEN did it happen? WHERE did it happen? 10

11 Fact Finding (continued) Internal Sources Medical records Communications with patient Admissions information Accident Reports (Attorney request, FOIA request) Insurance Companies (claim #, other insurers) Patient s Attorney 11

12 The Lien Act What is it? Health Care Services Lien Act: Statutory Cite 770 ILCS 23 It is a statute that prescribes how a health care provider or health care professional may recover a portion of a patient s personal injury recovery as payment toward the patient s medical bills, and it sets forth how much that health care provider or health care professional may recover. 12

13 How the Lien Act Works Entities that can be lienholders: Health Care Professionals: LICENSED physician, dentist, optometrist, naprapath, clinical psychologist, or physical therapist. Health Care Providers: LICENSED hospital, home health agency, ambulatory surgical treatment center, longterm care facilities, or emergency medical services personnel 13

14 Serving Liens Health Care Services Lien Act. Actually serving a Notice of Lien What is it? Why even do it? How do you do it? Who should you serve? Strict compliance vs. good enough (practical strategies to reduce costs). 14

15 Serving Liens (cont.) NOTICE Requirements: Contents: Name & address of injured person Date of injury Name & address of provider/professional Name of party alleged to be liable to injured person Service Via certified mail, registered mail or in person Served on injured person & party against whom the claim or right of action exists Who else you should serve? all attorneys, insurance carriers 15

16 Med-Pay What is Med-pay? A provision your patient may have on his/her automobile policy that will cover medical charges regardless of fault. Others in household may be eligible for benefits (ie. patient does not necessarily have to be policy-holder). Crucial for single-car accidents or where your patient is deemed at-fault. 16

17 Med-Pay (cont.) Fingers slammed in door? Stung by bee while driving? Sports injuries at school? Slip & fall? Often covers policy-holders who are bicycling and get into an accident with a vehicle or pedestrians hit by car. Med-Pay Interplay with Lien Act. 17

18 Third-Party Liability/ Bodily Injury Insurer for the at-fault party Passenger may have med-pay claim, TPL claim against driver of that vehicle, TPL claim against drivers of other vehicles What if driver of vehicle is not the owner? Your patient t-boned another driver does that mean your patient is at fault? Important note about Underinsured Motorist coverage. 18

19 Sending Out Your Documents THE RACE Whose team is fastest/best? Should you send UB/HCFA to insurer prior to sending out notice of lien? Should you wait until you have identified all of the parties before sending out lien notices? Cover letter identifying accounts. Importance of claim numbers. 19

20 Dealing With Patient s Attorneys 20

21 Dealing With Patient s Attorneys (cont.) Understand the Basics of the Lien Act (770 ILCS 23) 2 Categories Professionals and Providers 20% of patient s settlement allocated to each class, with unused portion from the one class being re-allocated to the other class, up to onethird of the patient s settlement 21

22 Dealing With Patient s Attorneys (cont.) Providers: SETTLEMENT/PI RECOVERY: Hospital, home health, ambulatory surgical treatment center, longterm care facility, emergency medical services personnel 20% (But see Stanton v. Rea) Professionals: Physician, dentist, optometrist, naprapath, clinical psychologist, physical therapist Unused portion reallocated to other category, not to exceed 1/3 of settlement 20% 22

23 Dealing With Patient s Attorneys (cont.) Tricks used to try to get you to reduce: The free medical records ploy. Demands that Medicare or Medicaid must be billed (Intent of MSP Statute & regs: to reduce the cost of the Medicare program by requiring Medicare to pay secondary to alternate sources. U.S. v. Sosnowski.) Common Fund doctrine. Lumping all lienholders together into one category. You must prove that services were related, even though you had the ER admission. Charges not reasonable. Subrogation Liens. 23

24 Dealing With Patient s Attorneys (cont.) Tricks to try to get you to reduce (continued): Failing to tell you that the policy limit settlement is only the tip of the iceberg. Failing to tell you that the dollar amounts of other lienholders are their total charges, not the amounts of the current balances. Unliened medical bills. Lost wages. Comparative Fault. Stanton v. Rea. 24

25 Dealing With Patient s Attorneys (cont.) Lien Adjudication What is a Lien Adjudication? Who can bring it? Who has to be served? What happens if you don t show? 25

26 Dealing With Patient s Attorneys (cont.) Stand your ground or make peace? Develop a scorecard for patient s attorneys. Beware the overly broad Release, where you think you are settling one $500 account and learn that you ve just inadvertently written off every outstanding balance for that patient. 26

27 It s a Small World Create notes for every entity you deal with on a regular basis for ease with future handling: Patient s attorneys. Insurers (eg. State Farm wants UB to come right after fax cover page, but before any cover letter). Police Departments. 27

28 Panel Discussion Practical hurdles to overcome in implementing a TPL program. Do the dollars involved make it worthwhile? How can a facility track the dollars involved and compare to the recoveries prior to implementing the program? What size staff should be allocated to this endeavor? 28

29 Questions? Please feel free to contact us offline: Jennifer Powers (847) ext. 202 David Moon (847) ext