Hospital Reimbursement Solutions

Trauma Center Case Studies
Issues: Inaccurate Information from the Insurance Company,
Timeliness of Appeal, and Contract misinperpretation
The patient was brought to the hospital through the emergency room as the result of a motor vehicle accident. The hospital contacted the insurance company and received pre-certification for two days. The patient required extended treatment, so the hospital again contacted the insurance company for authorization, and was advised that the patient’s coverage had termed. The hospital later discovered that the insurance company misinformed them as to the termination date and the patient was, in fact, covered during the entire inpatient stay. The hospital and HRS attempted several times to obtain a retro-authorization, but the insurance company denied the appeals by asserting that timeliness barred review. After extensive communications with the insurance company, HRS was able to convince the insurance company to review the account for retro-authorization. The claim was reviewed and all dates of service were approved.

Analysis and Disposition: The claim was sent back for reprocessing, and the insurance company paid the additional per diem amounts, but failed to pay the contractual add-ons, which included additional reimbursement for trauma team activation. HRS requested that the claim be reviewed for additional payment, but the insurance company again denied the review for timeliness. HRS disputed this denial, and the claim was sent to the appeals department for review. After a review of the contract, the insurance company approved and paid the additional amounts.

Issues: Chain of Payors, Silent PPO
The patient was brought to the hospital through the emergency room as a result of a motor vehicle – pedestrian accident. The patient’s injuries were quite extensive. The Hospital contacted the PPO for authorization per the directions of the patient’s insurance card. The PPO gave the hospital a tracking number for the authorization. The hospital later submitted the claim for payment, and the claim was denied for no authorization. The hospital placed a call to the PPO, and was advised that the group cancelled the authorization. The PPO provided no further explanation. The claim was then referred to HRS for resolution.

Analysis and Disposition: Through research, HRS discovered that the PPO was not responsible for pre-authorization or payment of claims, despite the listing on the insurance card. The group conducts its own pre-authorizations, and payment was issued by a TPA. HRS contacted the group, and requested a retro-authorization review of the services. The stay was approved at 100% payment for emergent services. A hard copy of the authorization was submitted to the TPA for processing. The TPA, after an extreme delay, asserted an unauthorized PPO discount which reduced payment to the hospital by more than $100,000. HRS disputed the discount by working directly with the medical director and the claims supervisor, and obtained the appropriate payment. Despite the complexity of the claim, the account was resolved in a little over 2 months.

Issue: Silent PPO, Statutory Interest
The patient was admitted to the hospital through the emergency room. The patient’s insurance coverage was through an out of state company which did not have a contract with the hospital. Upon processing of the claim, the insurance company took a PPO discount which resulted in a variance of over $10,000. The insurance company alleged that it had a contract with a national PPO, and that PPO had a direct contract with the hospital. The hospital advised the insurance company several times that the discount was unacceptable and billed charges were owed. The insurance company failed to respond to the hospital. The hospital then referred the account to HRS.

Analysis and Disposition: HRS reviewed the contract between the national PPO and the hospital and determined that the insurance company was not a listed payor during the dates of service. HRS demanded that the insurance company provide proof of the contract between the insurance company and the PPO which entitled them to a discount in this case. The insurance company was unable to provide such proof, and as a result HRS recovered full billed charges plus statutory interest of prime plus 6%. While this claim remained unresolved for over 3 years, HRS provided resolution within 4 months of referral.

Issues: Personal Injury, Silent PPO, Litigation, ERISA Administrative Appeal,
Exhaustion of Administrative Remedies
  The ERISA Plan and TPA initially pended this claim for receipt of settlement funds received by the patient as a result of the accident which caused the injury. After lengthy communications between the parties, HRS, the patient’s attorney and counsel for the TPA agreed that the claim would be processed for payment. Despite this agreement the TPA again pended payment in order to conduct an audit on the charges.      

In good faith the hospital, through HRS, agreed to the reduced amount proposed by the auditor in return for prompt payment. HRS was given the impression by counsel that payment would be issued in accordance with the agreed-upon terms. On the day prior to the payment deadline, after HRS placed several calls to confirm payment, HRS was advised that payment would not be issued on this claim because the patient dismissed her personal injury action against a possible defendant two years earlier.

Analysis and Disposition: Based on HRS’s review of the plan benefits pertaining to this matter, ERISA Plan and TPA were not entitled to deny payment for this reason. Additionally, HRS consulted with the patient’s attorney, and learned the dismissal was a requirement of the initial settlement. When HRS presented this information to counsel for the TPA, the attorney made it clear that the ERISA Plan and the TPA were firm on their decision to deny payment.

The ERISA Plan and the TPA essentially refused to resolve this matter in good faith by continuously pending and denying the claim. Discussions with the TPA made it clear that this claim would not be resolved short of litigation.

The case was litigated. HRS attorneys succeeded in court and the judge required the matter to go before the Board of Trustees of the ERISA plan for determination. HRS presented an extensive Administrative appeal.

HRS’s General Counsel, through extensive negotiations with the ERISA Plan attorney, settled the case at 80% of full charges.