Embed Size (px)
Citation preview
Don’t Let the Insurance Company Push You Around!KEYS TO GETTING YOUR BILLS PAID
Seva Law Firmwww.sevafirm.com
INSURANCE LITIGATION
SPECIALISTS
Presentation by Pratheep Sevanthinathan
Liability/Injury Insurers
Severely injured individuals often need home health care Liability policies are typically primary for reimbursement for injuries
Most common types of liability insurers you will deal with: Premise Liability Worker’s Compensation No-Fault Insurance
Reimbursement for premise and workplace injuries is challenging for home health agencies
Premise policies have reimbursement caps. Can be low. Worker’s comp rates are low.
No-Fault Auto insurance can be lucrative
Premise Liability
Accidents inside buildings Workplace accidents excluded Commercial and residential
Most common: “slip and falls” Falling objects Ceiling collapses
Patient must prove liability 100% contractual – limits to reimbursement:
Medical bills will be capped at the policy limits Residential policies are smaller Commercial policies can be larger
Worker’s Compensation
Workplace accidents Slip and falls Falling objects Auto accidents (company vehicle)
Medical reimbursement is set by a ”fee schedule.”
Not all services are covered by Worker’s Comp
WC Bureau (Administrative) No civil court remedies
No-Fault Insurance
Auto accidents Eligible for coverage even if you
cause accident Few exceptions to coverage that can
make reimbursement a pain Michigan is only state with unlimited
medical coverage! Insurer must reimburse reasonable,
necessary, and accident-related bills
No-Fault Insurance Incentives/Benefits
Why should my agency care for auto accident patients? All home health covered No caps Lifetime medical No automatic reductions
Almost everyone is covered by No-Fault Even if you don’t have car insurance Few exceptions
Submit Bills & Get Paid
Typical reimbursement process:1) Obtain a script for care;2) Determine the proper insurer, claim number,
and adjuster;3) Contact adjuster to determine if claims is open
and billable;4) Provide exemplary care;5) Maintain adequate records regarding care;6) Forward bill to the adjuster;7) Adjuster may request additional records or
information;8) Get paid!
Why am I not getting paid?Big Picture
Business model of an insurance company: For-profit Collect as much money as possible
(via premiums) Pay out as little as possible (in claims)
Every bill is thoroughly reviewed before payment is approved
Insurers will not pay any bills for which they are not legally responsible
Why am I not getting paid?Patient v Agency
Issues with patient Causation Necessity Statutory bar Policy cap
Issues with agency Rates Reasonableness Compliance with rules Service not covered
Why am I not getting paid?Patient Issues (Necessity of Services)
Lack of script/prescription “Independent” Medical Examination
Insurance company doctor hired to kill a claim
Adjuster will specifically ask IME doc whether home care is necessary
Why am I not getting paid?Patient Issues (Causation)
Exclusive remedies Premise cases – only responsible for
injuries arising out of the premise accident Worker’s comp – only responsible for
workplace accidents No-Fault – injury must arise out of the use
of a motor vehicle Source of care
Pre-existing condition Intervening/subsequent event Injury not covered under policy
Why am I not getting paid?Patient Issues (Other)
Statutory bar SOL Illegal claim Fraud
Policy cap Once policy limits on a premise policy
are exhausted, must look to next payment source.
Why am I not getting paid?Agency Issues
Rates – your rates are too high for the services you provide
Reasonableness – you provided more care than was actually prescribed or recommended
Compliance with rules – unlicensed, insufficient records, not enough improperly billed
Services not covered – worker’s comp does not cover all home health
Why am I not getting paid?The fly-by-night home health agency
No accreditation or licensing required for attendant care reimbursement under No-Fault Act
Opens the door for fraud Companies pop up just to serve a single
patient Muddies the water for legitimate home
health agencies Fly-by-night companies are ruining your
reputation Insurance companies will assume you are
fly-by-night unless you prove otherwise
How do I avoid denials?
Anticipate payment issues If the patient has
coverage/reimbursement issues you will not likely not get paid
Talk to the patient, adjuster, and patient’s attorney to see if there are any foreseeable issues with obtaining payment.
Was your referral source able to get paid? Discuss with the biller for the referral
source Avoid problematic claims if possible
How do I avoid denials?
Documentation! Well-maintained and detailed records are key Don’t leave the insurer any doubt that you
performed the services and worked hard Bill reasonably and logically
Set your rates within a reasonable deviation of the median
If you are just starting out, charge a little bit less Don’t be greedy
Get licensed and accredited Join a network, e.g. Cofinity Obtain a consulting report on your rates Know the law
What do I do if a bill is denied?
Determine the reason ASAP Is it a patient issue or an agency
issue? Will determine your next step Does the insurer have an appeals
process you can utilize? Have a standard appeals drafted to
use as a template Consider retaining an attorney
Don’t take no for an answer, get an attorney!
Attorney can represent your bill in two ways: Can represent your patient in an
action against the insurer Can represent your bill only
NO FEE unless bill is collected Insurance cases are typically handled
on a contingent basis I cannot speak for all attorneys
Benefits of hiring an attorney
Much more likely to get bills paid Patient issues can always be countered
through litigation No-Fault Act imposes heavy sanctions for
losing at trial. Puts pressure on insurance company to pay
Much more likely to get a larger portion of the bill paid
Insurance company will offer significantly more if they know you are willing to fight
Adjuster’s don’t like being dragged into court and will pay you extra to let them out
Drawbacks of hiring an attorney
You may get deposed Additional paperwork involved
(interrogatories) Attorney fee if there is a recovery
(although there are ways to obtain free services)
Basics of litigating insurance claims
Time is of the essence – know the statute of limitations. Communicate regularly with your attorney Intervention v direct suit? District court v circuit court? Distance yourself from the patient
You may have to invoke the “innocent third party doctrine”
Conclusion
Don’t operate in a manner than leaves you open for denials Be proactive about pursuing payment Be ready for a fight Know why your bills are being denied. Don’t shy away from legal action The benefits of litigating far outweigh the drawbacks Don’t give up on any bills!
Seva Law Firmwww.sevafirm.com
INSURANCE LITIGATION
SPECIALISTS
Presentation by Pratheep Sevanthinathan
QUESTIONS?
