WHAT ARE SOME OF THE HOT AREAS IN WHICH WE CAN HELP?

1. Finding Unknown (or Unconsidered) Coverage. There are a lot of weird situations which actually trigger coverage from an unlikely source. For example, even though motorcycle accidents are not usually covered by Michigan No-Fault, there are situations where it will provide coverage.

2. Coordination of Benefits. It is generally true that every carrier wants to be secondary to everybody else. And in many cases, they think they are. But often the actual language of the policy doesn’t exactly say what the carrier believes it says. So, for example, the policy may say it coordinates with no-fault, but the actual rules of the coordination provide that in this case, the no-fault carrier is primary!

3. Liens. Health plans increasingly adopt provisions that purport to give the plan the right to recover amounts they have paid. The U.S. Supreme Court has ruled that the effectiveness of these provisions often will depend on whether they would have been effective under common law (in this case, the medieval English Courts of Equity). Moreover, the results may vary depending on whether the case is filed in state or federal court. And the courts will take a hyper-technical view of the actual language used: a carrier using the word “subrogation” may lose, but might have won if it used the word “recovery.”

4. Medicare Secondary Payor Rules. The Medicare Act provides that Medicare is secondary to no-fault insurance. Similar rules apply to Medicaid. There rules are sometimes complicated and providers who violate them become subject to fines as well as having to refund any improper payments.

5. Medicare and Payor Audits. In an attempt to reduce its costs, the federal government is setting up new reviews to deny charges it doesn’t want to pay. We can help you prepare for, challenge, and defeat those reviews.

6. Silent PPOs. As originally envisioned, PPOs made sense: in exchange for a price discount, the carrier would encourage its insureds to use a provider’s services for prompt payment. But since those early days, things have changed. Carriers that that the provider may not have heard of and have never encouraged patient to use the provider’s claim they are entitled to the same discount the provider agreed to provide to somebody else. Such PPO agreements must be carefully drafted and negotiated and thoughtfully interpreted. These are services we can effectively provide.

7. COBRA and the Uninsured. Because of the downturn in the economy, many people are losing their health insurance coverage. In most cases, they are eligible for COBRA — and perhaps at a 65% discount. But were they properly informed of their rights? We address COBRA compliance and its impact for employers and providers.

8. Provider Networks. Through the years, carrier and market attitudes towards provider networks like physician-hospital organizations, physician organizations and what role they should ( assume risk, provide quality assurance and credentialing etc.) have ebbed and flowed. Today with pay for performance models and health reform and of some kind around the corner once again effective provider networks assuming a more important role in the health care delivery system. Based on years of experience representing provider networks we can assist in dealing with thorny legally sensitive issues of economic modeling, credentialing, peer review, and provider limitation or exclusion.

Health Provider Reimbursement

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