With the rise in healthcare for patients and the decrease in benefits, insurance companies are locking down on what they would consider an "overpayment." An overpayment occurs most often when there is a coordination of benefits problem. This means that there is (or should be) another primary source of payment rather than the private insurance that the patient provided you with.
Often times, patients don't want to bother with having to go to their car insurance plan and ask if they have MedPay, or they don't want to tell their employer than they were just hurt on the job. Patients feel it's “just easier” to use their private insurance. This could be very damaging to your A/R and your inflow.
As we've talked about in past articles, it's not up to the patient to pick and choose which insurance they want to use. If Mr. Smith was in a car accident and he has hurt his neck and his back, he will need to go to a doctor to be examined. If Mr. Smith is using Medicare or Blue Cross (or any other private payer) and he actually has MedPay available for situations such as this, you will need to inform the patient prior to treatment. Here's how a typical scenario plays out with MedPay:
Mr. Smith is driving his car, is rear-ended by the car behind him, and needs to be taken to the hospital for observation and examination. Upon entry, he hands over his Medicare and AARP card. The hospital releases him later that day and orders him to follow up with his physician and perhaps have some physical therapy.
Two days later, Mr. Smith is in a lot of pain and calls his physician. He gets a same-day appointment and the physician orders some light physical therapy to help alleviate his symptoms. Mr. Smith hands over his Medicare card and his AARP card. Since he's a returning patient, and nothing has changed with his insurance, a re-verification has not been completed.
Mr. Smith calls and makes an appointment for physical therapy, goes in and hands over the Medicare and AARP card. Once the patient is in the evaluation room with the therapist, it comes out that the patient was in an auto-related accident. The therapist asks if he has called his insurance company to open a claim, and the answer is “no, that's why I have health insurance.” Wrong answer Mr. Smith. It doesn't work that way.
Mr. Smith goes home and calls his auto insurance, opens a claim, finds out he has $1,000 in MedPay available (which is not a lot) for auto-related hospital or doctor-related visits. He calls the physical therapy company back and tells them his claim number and adjuster's name and phone number. Who do you think of these three people will be paid? The physical therapy company.
Once Medicare finds out that there was an auto accident (and they typically do) then MedPay becomes primary and all claims related to this injury will be denied by Medicare. AARP follows Medicare guidelines, so they deny, as well. But, here's the good news. Once the MedPay has been exhausted, the patient needs to call Medicare back and say, “I've used up my MedPay, but still need some more visits, and I need to go back to my doctor one more time, will you now become primary again?” They will most likely say yes. So, if you were the hospital and physician's office that the patient was seen in prior, you can still recover. You also have to get the patients claim number and adjusters name/number, send the claims off to MedPay, let them deny (this could take 90 days or more), and then send those denials to Medicare along with the claims. This process has now put you’re A/R into the 120+ category simply because Mr. Smith “didn't want to be bothered with it all.”
Another recent scenario that has come up is when a patient is injured on the job.
Mrs. Smith slips and falls on a wet surface in the hallway at work. That evening, she begins to have excruciating pain radiating down her leg from the fall. She calls her boss and tells him what happened; he calls the company's workers' compensation plan to open a case
Well, if you've ever seen workers' compensation patients, there is a very specific process that must be adhered to if you want to actually be paid for your services. So, the authorization process begins. This could take one week to three weeks, Meanwhile, the patient is still in pain, so she goes to her doctor and hands over her Aetna card.
About a week later, the patient is asked by Aetna if it was a work- or auto-related injury and replies "yes." Two weeks later, your billing department receives a denial stating “work-related injury, coordination of benefits not followed, denied.”
How do you recover from this? Your staff and the patient get on the phone immediately to the nurse case manager and ask for retro-authorization to begin the day Mrs. Smith walked into your office stating it was critical that she be seen. Some will give the retro-auth, and some won't. But, you need to try at the very least. Be ready with excellent chart notes to send over showing medical necessity.
As always, by getting the patient involved in their care, they will become more accountable for their overall well-being, and you are more likely to be paid for your services.