Accident claims management is complex. Patient accounts resulting from motor vehicle accidents and/or workers’ compensation injuries are largely paper-based and difficult to resolve. The skill set required to properly manage these claims is broad. A legal understanding of the state and federal laws is certainly a must, as is expertly trained registration and billing teams. The following 5 paragraphs explain areas required for the proper management of accident claims and help explain why many successful health systems have chosen to outsource these claims.
Most accident claims lack necessary information after registration is completed. Thus, the first step in ensuring proper management of these claims is to reach out to the patient and walk them through the potential benefits available to them in order to elicit correct insurance information. An effective team of outbound and inbound patient advocates is needed to walk patients through the complex world of coordination of benefits. A typical call center does not have the accident claim volume to merit hiring professional patient advocates that truly understand the issues. In addition to dedicated phone expertise, an effective mail campaign and web presence is also critical to success. At the end of the day, a multi-prong patient engagement strategy is critical to guarantee the correct insurance information is captured to ensure optimal reimbursement.
Once all relevant insurance information has been obtained, all coverage(s) must be verified. There are no electronic eligibility tools for Auto and Work Comp policies – which means that each potential coverage must be verified manually. Accident claim specialists must contact each identified Auto and Work Comp carrier to ensure both coverage and availability for No Fault, Liability, and/or Work Comp benefits. Following confirmation of coverage, each patient must be re-contacted to manually open a claim with the adjuster. Additionally, health coverage eligibility must be re-verified, with appropriate timely filling alerts set so that health billing deadlines are not missed while pursuing higher reimbursement rates from non-contracted, non-health payers.
Accident claim billing remains almost 100% manual, with no scheduling, no pre-registration, and no electronic transactions for (i) eligibility, (ii) claim submission, (iii) claim status, or (iv) remittance. Almost all claims billed to auto payers or work comp carriers are 100% manual and paper based. These claims require a great deal of follow up to simply ensure they are received, much less paid, translating to multiple billing cycles per claim. For work comp claims, a line-level code review should be performed prior to bill submission. For liability accounts, each claim must be verified with the patient’s attorney and then a lien must be filed or a letter of protection secured, resulting in additional costs for both the lien filing and certified mail requirements to put all parties on notice.
Once an accident claim is billed, most claims require significant follow-up to be successfully resolved. An initial call must be made simply to ensure the claim is received and in the proper format. Medical records must be obtained and delivered to the payers, based upon each payer’s differing requirements. And multiple calls are often required to ensure accurate payment is completed. No Fault payments are fairly straightforward but should each be reviewed, as payers are increasingly paying under silent PPO arrangements, with appeals needed for non-contracted PPOs. Similarly, all work comp payments should be reviewed to ensure payment was made correctly in accordance with the specific State fee schedule or UCR rate. Payments from liability settlements are either “paid in full” or are considered “reduction requests”. For the latter, negotiations should be led by an attorney that negotiates a high volume of these requests to ensure advantageous terms.
To ensure proper management of accident claims, detailed reporting is paramount. Claim volume, average balance, reimbursement rates, aging, paid in full %, distribution of payments by insurance type (MVAs only), registrar “information gathering” performance, timely filing, and compliance tracking are all important KPIs. When managed correctly, driven by reporting with full visibility, accident claims can often provide the highest reimbursement rates of any financial class.
Accident claim volume typically represents less than 3% of claims, yet can represent significantly more in terms of net revenue. For a $2BB GPR health system, there are often 4,000-5,000 accident claims annually. Given the labor intensive nature of these claims and lack of dedicated resources focused on them, many of these claims are incorrectly processed as Health claims or sent straight to Self Pay. For hospitals that do not dedicate appropriate resources to these claims, revenue is lost, patients are dissatisfied, and compliance risk is increased.
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