Optimizing Third Party Recovery

Transcription

1 Optimizing Third Party Recovery Elizabeth Richards, Esq. Cathy Dougherty, FHFMA Clinton A. Harkins, P.C.

2 Objective: Explore how an effective Third Party Accident Reimbursement program can contribute to your bottom line, especially in the face of the changing market under Health Reform.

3 Challenges to Reimbursement in an Obamacare Era More patients on Medicare/caid with lower reimbursement rates High deductible health plans Harder time collecting money from uninsured patients Primary Care physician shortage - overuse of ER Continuing pressure from insurance companies to lower rates

4 Meeting those Challenges Medicare/caid are payers of last resort. Allowing providers to seek full billed charges from primary payers. Hospital Liens may assist with collection of high deductibles and ER bills. Policies can be written so that these accounts are not considered self-pay and effective procedures can lead to collecting money from some uncollectible patients. Money from successful 3 rd party program can bolster money lost in other areas.

5 What is Third Party Reimbursement? Reimbursement for services rendered in which an entity other than the patient is responsible for the payment. Includes insurance companies of all types: auto insurance, liability insurance, workers compensation insurance, health insurance, even Medicare/caid This presentation will concentrate on the accident types of insurance: auto and other liability.

6 Hospital Liens in General Statutory documents filed with the court which allow for the hospital to be paid in cases where the patient recovers money for his or her injuries from a third party insurance company, as a result of an accident. While they can be complicated to file and perfect notice, they do not require a prior judgment or court hearing. Usually gives the hospital an absolute right to funds after attorney s fees. However, some states do limit hospital s access to the full settlement.

7 Georgia Hospital Liens O.C.G.A shall have a lien for the reasonable charges for hospital, nursing home, physician practice, or traumatic burn care medical practice care and treatment of an injured person, which lien shall be upon any and all causes of action accruing to the person to whom the care was furnished or to the legal representative of such person on account of injuries giving rise to the causes of action and which necessitated the hospital, nursing home, physician practice, or provider of traumatic burn care medical practice care, subject, however, to any attorney's lien

8 Alabama Hospital Liens Alabama Code Any person, firm, hospital authority or corporation operating a hospital in this state shall have a lien for all reasonable charges for hospital care, treatment and maintenance of an injured person who entered such hospital within one week after receiving such injuries, upon any and all actions, claims, counterclaims and demands accruing to the person to whom such care, treatment or maintenance was furnished, or accruing to the legal representatives of such person, and upon all judgments, settlements and settlement agreements entered into by virtue thereof on account of injuries giving rise to such actions, claims, counterclaims, demands, judgments, settlements or settlement agreements and which necessitated such hospital care, subject, however, to any attorney's lien.

9 Tennessee Hospital Liens Tenn. Code Ann Every person, firm, association, corporation, institution, or any governmental unit, including the state of Tennessee, any county or municipalities operating and maintaining a hospital in this. state, shall have a lien for all reasonable and necessary charges for hospital care, treatment and maintenance of ill or injured persons upon any and all causes of action, suits, claims, counterclaims or demands accruing to the person to whom such care, treatment or maintenance was furnished, or accruing to the legal representatives of such person in the case of such person's death, on account of illness or injuries giving rise to such causes of action or claims and which necessitated such hospital care, treatment and maintenance.

10 Florida Hospital Liens Hospital Liens are created by Special Laws and Ordinances in each particular county There is not a general Florida Statute Recent litigation on the constitutionality of this approach

11 Third Party Accident Reimbursement Challenges to a Successful Program Frequently dealing with non-contracted payers Patients normally hire attorneys (many TV ads) Fact finding is often necessary in order to locate correct payers. The patient may not even know who can/will pay the bill. Complex issue cases and low policy limits may require negotiation with involved attorneys Some state laws require the involvement of lawyers on behalf of the hospital

12 Interaction with Other Laws EMTALA- No issue unless you are pressing patient for information before stabilization FDCPA- Depending on wording of State Statute, Hospital Liens may not fall under the definition of debt under the act. Case Law is developing all over the country prohibiting the filing of Hospital Liens on patients with contracted health insurance

13 Interaction with Other Laws 501r Rules on Extraordinary Collection Activities Hoping for clarification from IRS Because Hospital Liens do not attach to a person or their property, they do not appear on their face to meet the IRS definition or intent of the statute. There is flexibility to write your charity care policy in a way to exclude this account type.

14 About Gwinnett Hospital System Lawrenceville Campus Acute care SNF Outpatient centers Neuroscience/stroke center Open heart Trauma Level 2 Pain management Clinics Duluth Campus Acute care Inpatient rehab center Outpatient centers Bariatrics Orthopedics Orthopedic ASC Clinics 13

15 Gwinnett Hospital System Stats Volume Statistics: Discharges: 26,490 ER visits: 137,796 Amb. Surgery: 26,766 OP Diagnostic: 207,598

16 GHS Hospital Lien Recovery Program Overall stats File an average of Hospital Liens a year Approximately $10-$11 million in billed charges Average recovery rate approximately $5-$6 million 35% of collections from patients with secondary Medicare/caid 65% of patients have no other insurance source Average time to collect a Hospital Lien days

17 Referral Process Electronic referrals at day one from discharge Electronic report includes traditional Medicare/Medicaid and Self pay accident occurrence code accounts with a balance over $1,000. Claims load into CAH Prescreen Department Accounts are reviewed and worked for accident details and liability information. Patient s are advised on admission that they may be contacted by CAH.

18 Notice to Patients Any patient who incurs medical services as the result of the negligence of a third party may be contacted by a representative of the law firm of Clinton A. Harkins. GHS has employed this firm to represent the hospital s interest in receiving reimbursement for medical expenses from third parties, such as automobile insurance companies. This firm does not wish to represent any GHS patient in a personal injury suit. Any questions regarding this service should be directed to Clinton A. Harkins at

19 Sample Case 1 Patient fell out of a moving golf cart on a turn in a gravel driveway. Patient treated at GHS. Billed charges $255k. Golf Carts are excluded under most auto policies Hospital s representative was able to work with patient s attorney and locate Homeowner s Policy with $600k in insurance. Liability Issues. Patient s attorney offered hospital $49, Hospital s attorney was able to participate in mediation and recover 1/3 of the final settlement, $116k, for the Hospital.

20 Sample Case 2 Motorcycle Accident. Speed and Aggressive Driving cited and patient charged with the wreck. Liability denied. Hospital Lien filed for $200k Hospital Representative investigated accident and worked with patient s attorney to uncover between $100k-$150k from 3 policies Hospital recovered $58k

21 Sample Case 3 Medicare patient involved in accident. Billed charges $83k. Patient s attorney advised hospital there was not much money, and they should take $10k medpay and bill Medicare. Turned out to be $250k Liability Policy Hospital recovered a total of $70k approximately 84% of billed charges.

22 Building a Successful Program Start on the Front End. The access staff must be able to capture key facts to help with the investigation of possible payers. Also, their coding of the account as an accident is crucial to getting these accounts worked property and timely. Know the law in your state. Make sure you aren t missing key time frames and notice requirements. Write your charity care policy to exclude these accounts. It will likely be necessary to have access to some legal assistance.

23 Ensure a Seat at the Negotiation Table

24 QUESTIONS? Contact info: Elizabeth Richards, Esq., FHFMA Clinton A. Harkins, P.C. Cathy Dougherty, FHFMA AVP Revenue Management Gwinnett Hospital System

25 About Gwinnett Hospital System (GHS) GHS is a 553-bed, not-for-profit healthcare network that provides a wide array of high-quality services and facilities to Lawrenceville, Duluth, Johns Creek and the Atlanta area, including a Level II trauma center. The system received America s 100 Best Hospitals Award from HealthGrades in 2012, one of only three Georgia hospitals to make this list.

26 About Clinton A. Harkins, P.C. Clinton A. Harkins, P.C. is a Law Firm in Marietta, GA which specializes in representing Hospital Clients in matters involving Third Party Reimbursement. With over 20 years experience in the industry, CAH represents hospitals all over the State of Georgia.