Liability Recovery Issues for Providers
Coordination of Benefits Denials
All health insurance subscriber contracts require the patient/subscriber to report any primary insurance coverage, especially if the injury was liability related. Without this information from the patient, the health insurance carrier can frequently legally deny the claim pending receipt of the information. The provider often has little contact with the patient after discharge and cannot force the patient to provide the information, and large health insurance claims go unpaid. TPR's strategy is effective in getting the health insurers to pay the claims.
Emergency Medical Condition Claim Reduction and the 14 Day Rule
In 2012 the Florida Legislature amended FS 627.736, Florida's No-Fault Auto Insurance law, require treatment for an injury associated with an accident within 14 days from the accident and applied two different coverage limits for PIP medical benefits, based upon the severity of the medical condition of the individual. An individual may receive up to $10,000 in medical benefits for services and care if a physician, osteopathic physician, dentist, physician's assistant or advanced registered nurse practitioner has determined that the injured person had an emergency medical condition (EMC). An EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to patient health, serious impairment to bodily functions, or serious dysfunction of a body organ or part. If an individual is not diagnosed with an emergency medical condition, the PIP carrier can limited the medical benefit limit to $2,500. In the absence of a definitive statement in the medical records, insurers routinely downgrade the care and limit the benefit which adversely effects healthcare providers and leaves underinsured patients with large account balances. TPR has a strategy to get most downgraded claims to be reinstated at the $10,000 benefit level.
Recovery from Underinsured Patients without a Hospital Lien
Injured patients without health insurance often have large remaining account balances, and no real assets or income to pay the charges. Personal Injury attorneys representing the patients may not have a legal responsibility to address the health care claim, leaving providers with insufficient recovery from patients. TPR's strategy effective addresses these situations and allows for maximum recovery of revenue for providers.
Recovery from Liability Carriers without a Lien
Its little known that liability/PIP carriers do not have to pay claims in the order they are received. Without a hospital lien, there is no, "First-in-time-first-in-right" claim payment. Carriers must only pay claims "fairly" and once benefits are exhausted typically have no responsibility and cannot be sued by providers for the failure to pay a claim. TPR's strategy makes the carriers treat a non-statutory lien claim with a priority status resulting in greater and more payment to providers.
Timely Claims Payments Enforcement
Florida law requires insurance carriers to make timely payments once a clean claim has been received. Often the carrier will deny receipt of the claim or state that it is under investigation to avoid the penalties associated with late payment. TPR's strategy documents receipt of the claim in a legally enforceable method and timely curtails frivolous investigations. The result is the recovery of substantial amounts of interests, costs and penalties from the carriers, which would not otherwise be recovered by the provider. The recovery amount is often several times the amount TPR charges its clients for yearly costs associated with recovery efforts! We call that Win/Win!
Questions?
It is not possible to list and expand on every issue that a medical provider may encounter in trying to recovery revenue, regardless of the source. The only bad question is the one not asked. We're here to help healthcare providers recover more revenue and welcome any questions you may have. There are probably some we haven't heard before, so go ahead - try us!