Six Challenges of Managing Accident and Workers Comp Claims

Posted by Michael Ford on Sep 28, 2015 10:49:00 AM
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Healthcare executives are faced with a variety of hurdles when managing motor vehicle and workers’ compensation related patient accounts. Here are six major challenges to be aware of in this realm of accident claims management, as well as some recommendations for overcoming them:

1) Patient Communication

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 coordination of benefits available in order to elicit correct insurance information. An effective team of outbound and inbound patient advocates and a multi-prong patient engagement strategy (phone expertise, mail campaign, and web presence) are critical to ensure the correct insurance information is captured needed to obtain optimal reimbursement.

2) Insurance Verification

Once all relevant insurance information has been obtained, all coverage(s) must be verified. Following coverage confirmation, each patient must be re-contacted to open a claim, and health coverage eligibility must be re-verified. MSP regulations require that both No Fault (MedPay/PIP) and Liability dollars be billed and fully exhausted prior to submission to Medicare (and Medicaid, as well, most of the time). Increasingly, commercial plans are adopting these “payer of last resort” rules, implying that it is more important than ever to pursue No Fault insurance before submitting a commercial claim.

3) Billing

All claims billed to an auto payer, and almost all workers’ comp carriers, are 100% manual and paper-based, which means they require a great deal of follow up to ensure they are received, much less paid. This translates to multiple billing cycles per claim. For workers’ comp, a line-level code review should be performed prior to bill submission. Not performing this review results in unnecessary denials and increased aging. For liability accounts, each claim must be verified with the patient’s attorney (or the adjuster) and then a lien must be filed or letter of protection secured, resulting in additional costs.

4) Follow-Up

Once an accident claim is billed, most claims require significant follow-up to successfully resolve. 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 workers’ comp payments should be reviewed to ensure payment was made correctly in accordance with the specific State fee schedule or UCR rate. Particular attention should be paid to work comp re-pricing firms. They should be countered with “negotiation from strength” using knowledge from a firm that negotiates with re-pricers nationally to obtain the highest reimbursement rates. For all “reduction request” payments from liability settlements, negotiations should be led by an attorney that negotiates these requests for a living to ensure optimal reimbursement.

5) Reporting

To ensure proper management of accident claims, detailed reporting is paramount. Claim volume, average balance, reimbursement rates, aging, paid in full percentage, distribution of payments by insurance type (MVAs only), registrar “information gathering” performance, timely filing, and compliance tracking (MSP in particular) are all important. When managed correctly, driven by reporting with full visibility, accident claims provide some of the highest reimbursement rates of any financial class.

6) Volume

Accident claim volume typically represents only 3% of claims, yet significantly more in terms of net revenue. Given the labor intensive nature of these claims, and the 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.

Click below to learn about the scope of the motor vehicle accident claims industry and key actions you should be taking to properly manage.

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