Title:
Download
1 / 11

Title: Tri-Service Denials Management Panel Session : W-1-1630 - PowerPoint PPT Presentation


  • 81 Views
  • Uploaded on

Title: Tri-Service Denials Management Panel Session : W-1-1630. Objectives. Provide basic understanding of the rules that apply to Third Party Collection Program denials management

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Title: Tri-Service Denials Management Panel Session : W-1-1630' - ahmed-benjamin


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

Title:Tri-Service Denials Management Panel

Session: W-1-1630


Objectives
Objectives

Provide basic understanding of the rules that apply to Third Party Collection Program denials management

Provide basic understanding of how health insurance benefits apply to Third Party Collection Program denials management

Provide basic understanding of how effective denials management reduces Third Party Collection Program Aged Accounts Receivables

Answer denials management questions


Overview
Overview

10 U.S.C 1095 and 32 C.F.R 220

Health Insurance Benefits

Reducing your Accounts Receivables


10 u s c 1095 and 32 c f r 220
10 U.S.C 1095 and 32 C.F.R 220

  • 10 United States Code 1095

    • Established the Third Party Collection Program

    • Backbone of Denials Management

    • Contains broad language about how Third Party Payers reimburse MTF claims

  • 32 Code of Federal Regulations 220

    • Implements 10 U.S.C. 1095

    • Further defines the intent of 10 U.S.C. 1095

    • 14 Sections Contain Specific Language

      • Sec 220.2 Statutory obligation of third party payers

      • Sec 220.3 Impermissible exclusions

      • Federal Digital System: http://www.gpo.gov/fdsys


Using 32 c f r 220
Using 32 C.F.R 220

  • Out of Network (OON)

    • 32 C.F.R 220.3(c)(4) – Exclusions Impermissible

  • Reduced Allowed Amount

    • 32 C.F.R 220.3(c)(4) – Exclusions Impermissible

  • Medicare EOB/RAs

    • 32 C.F.R 220.10(d) – Medicare EOB Not Required

  • Reduced Number Of Allowed Inpatient days

    • 32 C.F.R 220.4(c)((2)(iii) – Utilization Review Provisions

    • 32 C.F.R 220.8(b) – Reasonable Charges Established

  • Offsets/Take Backs

    • 32 C.F.R. 220.7(d) – A Third Party Payer May Not Offset


Health insurance benefits
Health Insurance Benefits

  • 32 C.F.R 220.4–Permissible Terms and Conditions of Health Plan

  • Obtaining Benefits

    • Employer Group Number

    • Benefit Web sites, for example: www.opm.gov/insure/health/planinfo/index.asp

    • www.navinet.net

  • Documenting Benefits

    • Capture in software

    • Create a spreadsheet


Health insurance benefits1
Health Insurance Benefits

  • Using Benefits

    • Valid or Invalid

    • Service-Specific Guidelines

  • Responding to Invalid Denials

    • Letter Templates

    • Service-Specific Guidelines

  • Denials Not Resolved in Your Favor

    • 32 C.F.R 220.7: The United States has the right to institute and prosecute legal proceedings to enforce the provisions of 10 U.S.C 1095

    • Referring invalid denials to Legal

    • Service-Specific Guidelines


Aged accounts receivable
Aged Accounts Receivable

Effective denials management reduces Aged Accounts Receivables


Aged accounts receivable1
Aged Accounts Receivable

TPCP OUTPATIENT RATIOS

Source: TMA UBO Metrics Report


Q&A

Questions For Tri-Service Denials Management Panel


Summary
Summary

Use 10 U.S.C 1095 and 32 C.F.R. 220 to effect payment

Obtain health insurance benefits to properly identify valid and invalid denials

An effective Denials Management Program reduces your Aged Accounts Receivables and increases your collected-to-billed ratio

Contact your Service Representative for service-specific guidelines


ad