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Tip 5

Best Practices: Patient Intake and No-Fault’s 45-Day Rule

Erin S. Stamper & Bruce Klein

Common billing issues exist across a broad-spectrum of the Firm’s hospital clients. One of the most common issues involves the ability of the hospital to timely identify and bill the correct insurer or “primary payer” in the first instance, whether that be a commercial, government, no-fault, liability, or workers’ compensation payer. The failure to timely identify and bill the correct insurer leads to time and effort wasted by billing departments, a delay in the payment of hospital claims, and to a decrease in a hospitals’ net receivables.

In the no-fault realm, this issue is compounded by the 45-Day Rule, which mandates that claims for reimbursement be submitted within forty-five days of the date of service. Often, the hospital’s failure to timely identify and bill the no-fault insurer is attributable to an error made during the patient’s initial intake at the hospital. While mistakes made during a patient’s initial intake would appear to be easily fixed, said errors are often not corrected by the hospital’s billing department once they should have been identified. Thus, initially excusable billing errors become uncorrectable and the underlying claims, uncollectible.

With the implementation of the ICD-10 Procedure Coding System, which documents both the etiology of disease and the severity of illness, insurers can now more easily identify improperly billed claims, for which they are not obligated to afford primary medical coverage. As such, both commercial and government insurers are denying misbilled claims at a higher rate and, in order to protect its accounts receivable, the hospital is under increased pressure to correctly identify and bill the primary payer in the first instance. Inconsistencies between the type of insurer/payer identified (i.e. commercial, government, no-fault, liability, or workers’ compensation) during the patient’s initial intake and the ICD-10 codes selected must be flagged and corrected by the hospital’s billing department as early as possible—ideally, before the claim is improperly billed. However, to the extent that the hospital’s first notice of a billing error is its receipt of a denial from either the commercial or government insurer indicating that no-fault is primary, then the hospital must rebill the no-fault insurer as soon as possible but, in no event, more than forty-five days from the date that it receives the no-fault insurance information.

Issue 1 (Initial Intake):

As most people have experienced, upon arrival to a doctor’s office, the front desk staff routinely asks the patient whether the insurance information on file has changed since the patient’s last visit. While the answer to this question may establish whether or not the patient still has coverage through a particular insurance carrier, it does not establish whether the medical treatment to be rendered by the hospital is coverable by said insurance carrier. In order to identify the insurer responsible for “covering” the treatment a.k.a. the primary payer, the hospital must first ascertain the underlying cause of the patient’s condition. Therefore, the questions that must be asked during the patient’s intake are as follows:

What brings you to the doctor today?

Is the visit for an injury that is work-related?

Is the visit for an injury that is auto-related?

To protect its net receivables, the hospital’s intake process must be designed to ensure that the underlying cause of the patient’s condition is identified. Obtaining said information, in the first instance, is the only way to ensure that the primary payer, i.e. the insurer that pays first, is identified and billed in a timely manner. As previously stated, obtaining said information, in the first instance, is especially important when the treatment is related to an automobile accident as said reimbursement claims must be submitted within forty-five days of the date services are rendered.

Issue 2 (Rebilling the No-Fault Insurer):

The Firm has been informed by the vast majority of its hospital clients that their intake personnel are trained to establish the reason for the patient’s visit and to process all types of insurance (commercial, government, no-fault, liability, and workers’ compensation). Despite said training, the wrong payer is sometimes identified and billed by the hospital. If the wrong payer is identified initially, it may not be discovered until later in the billing process, at which point, remedial measures must be taken by the hospital’s billing department. As such, hospitals must assess their current billing procedures to ascertain what events, if any, are set to trigger the re-review of a claim for accuracy, whether or not it has already been billed. For example:

If the ICD-10 codes chosen indicate that the claim is not related to the insurance on file, what does the billing department do then?

When the insurer that is initially billed denies the hospital’s claim as uncoverable because it is no-fault related, what does the billing department do then?

To contextualize the foregoing issues, below are a few billing scenarios that have been observed by the Firm:

  1. Patient is treated in the emergency room or at a clinic for the flu but the claim is billed to the no-fault insurer on file. Even after receiving a denial from the no-fault insurer, the claim is not re-billed to the appropriate insurer.
  2. Patient is treated in the emergency for injuries sustained in an automobile accident but the bill is sent to a commercial carrier. The commercial carrier does not immediately identify the claim as being auto-related.
  3. Surgery is performed at the hospital by an employed physician, whose operative report clearly indicate, by history, that the surgery is related to an automobile accident. Despite this, the surgery is billed to a commercial carrier. The follow-up visits, however, are directed to the no-fault insurer, which has no record of the surgery performed.
  4. Cancer is billed to the no-fault.

Conclusion

As New York State’s premier filer of hospital no-fault arbitrations, the Firm is in a position to identify decisional trends as related to the 45-Day Rule. If the no-fault insurer is misidentified and not billed in the first instance, it is likely that the hospital’s claim will be denied by the no-fault insurer based on the hospital’s failure to comply with the 45-Day Rule. Arbitration awards indicate that the hospital will have a greater likelihood of prevailing over a 45-Day Rule denial when the services it provided were emergent in nature or where there the etiology of the patient’s condition is in question. Additionally, the hospital increases its chances of overcoming a 45-Day Rule when it abides by the following best practices:

  1. If the ICD-10 codes utilized conflict with the insurance information taken during the patient’s intake to the hospital, then measures must be immediately taken to identify and bill the correct insurer.
  2. Upon receipt of a denial from a commercial or government insurer indicating that no-fault is primary, the hospital must rebill the no-fault insurer as soon as possible but, in no event, later than forty-five days from the date that it obtains the correct no-fault insurance information.
  3. A bill’s submission to the no-fault insurer should not be delayed so that it can be submitted along with the corresponding medical records; rather, to ensure compliance with the 45-Day Rule, a bill should be forwarded to the no-fault insurer within forty-five days of the date that the services were rendered, regardless of whether the medical records are available. If requested, the medical records may be submitted at a later date.
  4. Upon receipt of a 45-Day Rule denial from the no-fault insurer, the hospital must submit a request for reconsideration within thirty days.
  5. The hospital’s request for reconsideration must accurately detail the reason for its late submission of the claim to the no-fault insurer, the steps taken by the hospital to obtain the patient’s insurance information, and the date that the hospital received the information needed to rebill the no-fault insurer.
  6. When a claim involving a 45-Day Rule denial is referred for arbitration, the Firm may seek an affidavit or testimony from a supervisor of the Hospital’s billing department to explain the steps that the hospital took to timely identify and bill the correct no-fault insurer, and to discuss the request for reconsideration that was made by the Hospital upon its receipt of the 45-Day Rule denial. As such, all such steps should be documented in the patient’s billing file and copies of all related correspondence should be saved.

What Sets Us Apart From Our Competitors?

The Three C's: Collection, Consulting, Compliance
  • Fighting for Compensation

    We use negotiation, arbitration, or litigation to ensure medical providers are fairly compensated for their services.

  • Experienced Attorneys

    We have a team of trusted and respected attorneys to ensure your case is matched with the best attorney possible.

  • Client-Focused Approach

    We’re a client-centered, results-oriented firm. When you work with us, you can have confidence we’ll put your best interests at the forefront of your case – it’s that simple.

  • We'll Fly to You

    We fly throughout New England to meet with medical providers and hospitals to help them with collection, consulting and compliance.

  • Creative & Innovative Solutions

    No two cases are the same, and their solutions shouldn’t be either. Our attorneys provide creative points of view to yield exemplary results.

What Sets Us Apart From Our Competitors?

  • Fighting for Compensation

    We use negotiation, arbitration, or litigation to ensure medical providers are fairly compensated for their services.

  • Experienced Attorneys

    We have a team of trusted and respected attorneys to ensure your case is matched with the best attorney possible.

  • Client-Focused Approach

    We’re a client-centered, results-oriented firm. When you work with us, you can have confidence we’ll put your best interests at the forefront of your case – it’s that simple.

  • We'll Fly to You

    We fly throughout New England to meet with medical providers and hospitals to help them with collection, consulting and compliance.

  • Creative & Innovative Solutions

    No two cases are the same, and their solutions shouldn’t be either. Our attorneys provide creative points of view to yield exemplary results.

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