Training Primer - Insurance

The complexity of medical billing is compounded by health insurance. You can have 100 people, each may have different types of health benefits through 100 different insurance companies. One policy could be primary and under State law jurisdiction and you can have 50 that are also primary and under Federal Law jurisdiction. You could have some with auto accident or workers compensation coverage. You could have some who have multiple health benefits that is could be considered secondary coverage.

Payment of the health benefit is based on (a) applicable State or Federal law, (b), a contract with the provider or (c) a contract with an employer or the patient themselves. You may have health insurance laws that regulate what is called Coordination of Benefits. In simplistic terms, Coordination of Benefits (COB) is communication with a patient's insurance companies where each insurance company determines it is primary or secondary. The determination of COB is NOT the doctors responsibility, but some insurance companies will deny benefit payment stating the doctor did not coordinate the benefits. What ths doctor should do is verify, verify, verify that coverage or health benefits are available and the medical care about to be received is a covered service, and to send the claim to the correct insurance company.

one thing you must be on the watch for are the payments. Lets say your doctor has a charge of $100. the patient ha ABC Insurance and XYZ insurance. ABC pays $80 and XYZ pays $50. Youve been overpaid $30. You cannot keep the overpayment regardless of how the doctor or billing company feels. You also cannot say if the insurance company wants their money back, they have to ask for it first. Im not a lawyer, but I am sure a regulatory agency or investigator will say you are comitting fraud through the misreprentation of your true charges. if ABC or XYZ has a contract with a federal program, it might be said you submitted a false claim. How is this possible? When you submitted the claim, you represented your services as costing $100. You told the patient's insurance company that the service cost $100. When being paid $130 and not returning the overpayment of $130, you actually represent your charges as $130. Hence the false charge. It might also be said you might be in violation of other Federal laws. By accepting the overpayment, you might be inducing the patient to return to you as a self referral, as a means of unjust enrichment at the expense of the patient and their insurance company or having the patient refer others to you. "Hey Martha, you need to go see Dr.Doctor, you'll never get a bill. The insurance company owed the overpayment could perform retroactive review of your claims. if it is determined that fraud is involved, they could perform a relook at the claims going back 10 years. That $30 could add up to $300,000 and that is a nice inducement to filing a lawsuit to recoup not only the overpayment but the actual payment itself, but interest and penalties as well.

Some insurance companies may be contracted as primary, so when ABC is primary and it pays as primary, XYZ isnt processing the claim as primary as well, so ABC may be contracted to pay 100% of charges and XYZ may be contracted to pay 100% of charges as well. Some insurance companies dont want any overpayments sent to them. They may direct you to send the overpayment to the patient/guarantor/insured. Our policy is to get overpayment instructions, in writing from the insurance company. You dont want to contact ABC by phone with Mrs. Whiggins, from custmomer service, telling you to send the overpayment to the patient, only to have ABC contact you, 4-5 years later to demand the overpayment. Mrs. Whiggins may have quit or she may deny telling you anything. When we process overpayments, we do the following:

1. The EOB is scanned and saved to DVD.

2. Notes are placed in the patient's account outlining the overpayment, return of the overpayment to and includng the date, where the overpayment was sent, Check number, Check amount, a scanned image of the check, the letter to the insurance company or patient regarding the overpayment is saved to DVD with the other scanned images, scanned image of the certified mail receipt and scanned image of the return receipt when it is received. if the insurance company was contacted by phone, a synopsis of the call is documented, to an include date, time, your name, who you called, number called, who you spoke with and their response. If we returned the overpayment to the insurance company, we cc'd the patient. If we sent it to the patient, we cc'd the insurance company.

3. Follow office/compliance plan regarding overpayments, which includes what to do if the overpayment is denied or returned, Your policy may dictate that the returned or denied overpayment is sent to the State unclaimed funds department of the State Treasurer as may be required by applicable State law.

is this alot of work? Not if you consider the consequences of an investigation, audit, or lawsuit. You want everything as concrete as possible to show you used due diligence to return the overpayment.

I oncd worked for a doctor who said, you do not return any overpayments. This was an order I could not obey. I did contact the commercial insurance company, in writing, informing them of the overpayment. The letter showed they overpaid $X, if they did not object, in writing, within the timeframe shown in the applicable State law, I could apply the overpayment to a claim that was underpaid or not paid at all. i did not do this with Medicare. Medicare always received a check. Most commercial insurance companies never responded. My letters went directly to the insurance company CEO. Now, do I recommend doing this? Nope, No way, no how. Im just saying what i did. The best advice is to return the overpayment.

When working for a doctor, you need to know the doctors insurance company contracts as to how the contract requires the insurance company to pay as primary and secondary. if you have Medicare patients, know Medicare's secondary payer (MSP) rules. the same is with medicaid. Become familiar with the patient's insurance. Obtain and verify this informatiion. Get all the insurance information and copies of all insurance cards, and most inportant, VWERIFY, VERIFY, VERIFY! Also, become very familiar with your State COB rules. You might send a claim to ABC and XYZ. XYZ may deny payment stating that the primary paid more than what they would have paid. If you look at the patients summary plan description (SPD) or health benefit manual, you may see that XYZ is required to pay what ABC didnt pay. XYZ may only be required to pay 40% of their allowed amount with the patient paying the 60% of the allowed amount, including any and all amounts of the balance of the providers charges. You may be interacting with a patient with Medicare and VA benefits. Learn what is required when this happens.

You have to be on top of all of the madness that accompanies claims and you have to be 100% correct all of the time. You also have to be in compliance with the doctor's contract, applicable laws and ensure patient compliance with their insurance company rules and contracts they or their employer signed. Follow the doctor's and your compliance plans. If you have employees, ensure they are properly trained and they undergo followup training to stay current and in compliance.

	Author	Topic: Training Primer - Insurance (Read 473 times)
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