Out of Network-how to get pre authorizations or referrals to protect your bottom line

Webinar Description

Pre-authorizations and referrals are one of the most important parts of your medical practice. If you are seeing patients out of network, even more so! Let us show you how to simplify this process and save valuable time for your staff and practice.

According to studies 76% say pre-authorizations lead to patients stopping recommending treatments! We cannot allow payers to determine how patients are treated, this webinar will allow your practice to take back that power and get authorizations and referrals the first time. We will show your team tips on how to identify what payers are looking for and what to provide in requests to get better results from their hard work!

Make sure your entire care team attends this very informative webinar, this will protect your bottom line. Missed, denied or incorrect referrals or authorizations can be extremely detrimental for a medical practice. These errors or oversights can cost your practice thousands of dollars and usually cannot be recovered. Let us help you put processes in place to NEVER miss or have another denied or missed payment for a procedure or visit. It is possible!

Webinar Objectives

• Missed revenue for denied or absent authorizations/referrals
• Excessive work to try to get retro-authorizations/referrals
• Incorrect processes for auths/referrals
• Payer rules and regulations not known or being followed
• Denials of claims for coding issues on auths/referrals
• Incorrect payer auths (changed insurance)
• Referral visits running out
• Incorrect provider/facility authorized

Webinar Agenda

Issues we see often, things we can control, areas to improve, tools for success, processes to implement

Webinar Highlights

• Patient information-be sure you have all the pieces of the puzzle
• Payer policies, how to decode
• Internal processes for success
• Follow up-OFTEN
• How to deal with denials

Who Should Attend?

• Medical office staff
• administrators
• office managers
• pre-authorization staff
• billing staff
• billing managers
• front desk staff
• medical assistants
• practitioners (MD, DO, PA, NP, CRNA, etc)

The New Federal No Surprise Act – Impact on Out-of-Network Providers

Webinar Description

This webinar by industry expert speaker and renowned attorney Thomas J. Force, Esq. is intended to break down the new Federal No Surprises Act, enacted as part of the Consolidated Appropriations Act, 2011, which is intended to protect patients from “surprise” medical bills, including those arising when out-of-network providers utilize and provide services at an in-network facility. Essentially, the goal of the No Surprises Act is to remove the patient from serving as the intermediary between the insurer/payor and the provider/practice.

The program will first help you determine whether the No Surprises Act affects your practice and, if so, provide considerable insight into the detailed requirements and processes underlying the Act. The No Surprises Act contains many requirements that may result in difficult decisions having to be made, depending on the nature of your practice.  Such decisions and considerations will include, among others:

• Whether to provide the notice and secure the consent of the patient required in order to balance bill the patient or, alternatively, refrain therefrom to allow for use of the Independent Dispute Resolution (IDR) process.
• How to proceed through the IDR process, if this is the avenue selected, including how to appropriately calculate the offer submitted to the IDR entity (i.e., the arbitrator that will decide between the amounts submitted by the provider/practice and insurer/payor, respectively).

To aid you in making such determinations in the future, the program will set forth key aspects of the No Surprises Act, such as:  

• How future rules and regulations promulgated by HHS in the near future may affect your determinations;
• An overview of the IDR process, including timelines related thereto;
• How the IDR entity makes a decision and the factors that it can consider; 
• The IDR waiting period and batching of claims;
• Other cost considerations (e.g., how the IDR entity is paid); 
• The impact that previous IDR determinations will have on future negotiations and/or IDR entity determinations; 
• The impact of and relationship to State Law; and
• For the notice and consent requirement for balance billing:
  • Timeframes for providing notice and securing consent;
  • Required notice contents;
  • Required consent contents.

Put simply, this program will provide you with the necessary tools and insight to understand how to effectively navigate the road ahead, as a result of the No Surprises Act, based on the specifics of your practice and its operation.

Webinar Objectives

This webinar will address the following areas of concern:

• What to consider in determining whether to balance bill your patients or take advantage of the IDR process established by the No Surprises Act;
• Risks of relying on the IDR process or inappropriately calculating the extent of an “offer” to be submitted to the IDR entity;
• Avoiding delays or other hindrances to your revenue cycle, particularly based on the availability and restrictions of the IDR process; and
• Potential pitfalls experienced in attempting to satisfy the notice and consent requirement for balance billing.

Webinar Agenda

• Introduction to the No Surprises Act
• The Effect of the No Surprises Act on Health Insurers/Payers
• The IDR Process – Overview and Specifics
• Notice and Consent Requirements – Overview and Specifics
• Additional Aspects of the No Surprises Act
• Key Takeaways

Webinar Highlights

• The goals underlying the No Surprises Act
• How your practice may be affected by the No Surprises Act
• The IDR Process – Overview and timeframes
• The IDR Process – Decision-making considerations
• The IDR Process – How to submit an offer that will provide the best results, both for the immediate claim(s) at issue, but also for future claims.
• The IDR Process – Limitations, concerns, and exceptions 
• How to satisfy the notice and consent requirements for balance billing

Who Should Attend

Healthcare professionals (doctors, surgeons, mid-level providers – nurse practitioners and physician assistants), particularly those who are out-of-network, as well as medical practice owners, managers, and operators, will find this program beneficial.

Lessons Learned from the Cigna and Aetna cases against Humble Surgical Hospital

Webinar Description

This information-packed webinar by expert speaker Thomas J. Force, Esq. will discuss two court cases involving Cigna v. Humble Hospital and Aetna v. Humble Hospital. The facts of the cases and findings and holdings of the Courts will be discussed and explained. Both cases involve an out-of-network hospital and issues with its billing practices. Mr. Force will explain how the findings in these cases can impact providers based upon their disclosures to insurers and patients, their billing practices, and referral programs.  Mr. Force will walk the attendees through each case and the appeal of the Cigna case. He will discuss the outcomes of the cases and how they affected the financial status of the hospital.

Based on those findings, Mr. Force will instruct medical providers and their revenue recovery staff on how to maintain compliance and avoid litigation while collecting the proper amount of money from patients and their health plans. This session will explain how you may avoid compliance pitfalls and litigation by health plans. There will be an analysis of litigation pertaining to out-of-network healthcare providers, “fee forgiveness”, “balance billing” patients, and ERISA regulations and requirements.

Webinar Objectives

By attending this informative session, you will learn important court cases, their findings, and strategies that will assist your practice in avoiding health plan audits and litigation based upon fee forgiveness, referral arrangements and failure to balance bill patients. You will learn the do’s and don’ts regarding how to effectively balance bill your patients and the implications of being non-compliant.

Attendees will get a comprehensive overview of what a provider is entitled to under ERISA and needs to be doing to remain compliant, including best practices to get claims paid by having a valid assignment of benefits, and to avoid balance billing audits, overpayment demands, recoupment and litigation by insurers.

Webinar Agenda

• The background and facts of the Cigna v. Humble case
• The Court findings of the Cigna v. Humble case
• The background and facts of the Aetna v. Humble case
• The Court findings of the Aetna v. Humble case
• The Appeal of the Cigna v. Humble case
• The cases involve an out-of-network hospital and its billing practices and referral programs
• The issues in the cases involve allegations of fee-forgiving by the provider, overpayment claims, fraud and misrepresentation and referral and use fees.
• The cases also address the providers’ rights under ERISA, including full and fair review of its claims and the right to receive plan documents
• Texas law prohibits hospitals from billing patients and health plans differently (Tex. Ins. Code § 1204.055; Tex. Oee. Code § 101.201); hence the claims submitted to Aetna were fraudulent.
• What type of arrangement is considered a kickback to physicians
• What happened to Humble Hospital as a result of the litigations
• A discussion of ERISA 

Webinar Highlights

• The attendee will learn why they should never agree in advance to waive or limit cost-sharing from patients and not make promises that they will be the same or better off than if they used in-network facilities.
• Any financial assistance policies must be uniformly applied and allow for reasonable verification of the applicants’ information. Why Payment plans, if offered, should be without interest.
• How to handle balance billing in a compliant manner.
• The importance of making proper disclosures that you are “out of network”.
• Importance of patient signed, valid assignment of benefits that also includes the right to pursue all of the members’ legal and equitable remedies as “beneficiaries” of a plan.
• Personal payment obligation agreements for any claims for services later denied payment as “not covered” or for which the patient was ineligible on the dates the services were performed
• If an ERISA plan grants to the plan administrator the “discretion” to interpret and apply plan language, the administrator may exercise that right in any way that is reasonable and that is supported by the facts even if others – including a court – reasonably may disagree.
• The dangers of referral programs.
• Plans cannot stop paying claims as otherwise required by contract or by law simply because there is a pending  balance billing audit of the provider.
• Until a plan has processed a claim and issued an explanation of benefits, a provider cannot determine the allowable amounts necessary to calculate the balance personally due from the plan members/patients .
• Insurers must respond to demands made by providers for plan documents and other documents under ERISA and the failure of the insurer to do so when specifically requested constituted “bad faith”.

Who Should Attend?

• Medical Practices – Owners and Revenue Cycle personnel
• Medical Facilities- Owners and Revenue Cycle personnel
• Healthcare Consultants
• Healthcare Attorneys
• OON healthcare providers
• Ambulatory surgery centers
• Consultants for providers and facilities

How to Defend Against Insurance Company Recoupments, Repayment Demands, and SIU Audits

Webinar Description

Out of network (OON) providers keep facing recoupment, refund demand and so-called special investigations (SIUs) from insurance payers and health plan. If you are an out of network provider, it is imperative that you balance bill your patients for the difference between charge and payment. The Webinar will discuss what a recoupment and audit is, the reasons that insurance companies state are the reasons for the overpayments and what steps should be taken to defend against the insurance company’s overpayment demands.  The Webinar will address the ERISA obligations and protections and the importance of a provider obtaining a valid Assignment of Benefits. It will also set forth the notifications which must be sent out by the insurance company when it conducts an audit and seeks recoupment.  

Sign up for this 60 min webinar where industry veteran Thomas J. Force, ESQ. will discuss the concept of full and fair review and that recoupment demands are considered “adverse benefit determinations”.  He will advise the attendees of what information they are entitled to so that they can respond to and defend the audit findings and recoupment demands. Thomas will also discuss various court cases on these issues and most common basis for recoupments, such as services not covered under the plan or non-compliant.

Webinar Objectives

• How to respond to an audit and refund demand by never refunding money without demanding a written explanation for the recoupment.
• How to respond to an audit and refund demand by verifying its accuracy.
• How to object to a recoupment in writing.
• About relevant court cases.
• How to make written ERISA Demands in objection letters.
• What to do if the insurance company does not comply with ERISA demands.
• About relevant state insurance laws.
• The time frames for seeking recoupment.
• About the importance of obtaining a valid and enforceable AOB.
• About mandatory information which must be provided to them during an audit.

Webinar Agenda

• How to Defend Against Insurance Company Recoupments, Repayment Demands, and SIU Audits
• What is a Recoupment?
• Characteristics of Recoupment Letter
• Understanding Basic ERISA Obligations
• Full and Fair Review
• Recent Court Cases
• Importance of obtaining Valid and Enforceable AOBs
• When faced with a Recoupment
• Unsupported Services
• Interplay with Insurance Law
• Is ERISA Demands are Not Met
• If the Insurance Company Does Not Comply with ERISA Demands

Webinar Highlights

• What should be done when a provider receives an audit or overpayment demand.
• How to object, appeal, hire an expert and make document requests.
• The state insurance laws regarding time frames to request recoupments.
• What happens when the insurance company does not comply with the ERISA demands.

Who Should Attend?

• In and Out of Network Providers
• Medical Billing Companies
• Providers’ Office Staff
• Physician, Facilities
• Healthcare attorneys