Don't Let the Insurance Company Push you Around! Keys to Getting Your Bills Paid
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This presentation was given on May 14, 2014 at the Michigan Association for Home Care by Seva Law Firm Owner and Attorney, Pratheep Sevanthinathan. Seva Law Firm specializes in insurance litigation.
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Don't Let the Insurance Company Push you Around! Keys to Getting Your Bills Paid
- 1. Don’t Let the Insurance Company Push You Around! KEYS TO GETTING YOUR BILLS PAID
- 2. Seva Law Firm www.sevafirm.com INSURANCE LITIGATION SPECIALISTS Presentation by Pratheep Sevanthinathan seva@sevafirm.com
- 3. 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
- 4. 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
- 5. 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
- 6. 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
- 7. 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
- 8. 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!
- 9. 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
- 10. 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
- 11. 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
- 12. 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
- 13. 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.
- 14. 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
- 15. 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
- 16. 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
- 17. 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
- 18. 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
- 19. 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
- 20. 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
- 21. 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)
- 22. 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”
- 23. 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!
- 24. Seva Law Firm www.sevafirm.com INSURANCE LITIGATION SPECIALISTS Presentation by Pratheep Sevanthinathan seva@sevafirm.com
- 25. QUESTIONS?