- An unprecedented 50% of the nation’s hospitals losing money from operations. (Thomson Reuters)
- Trauma centers and emergency departments across the U.S. have been closing at alarming rates.
- The burden of uncompensated care is growing, resulting in 1.) Decreasing resources and critical access to care for patients and 2.) The threat of less specialists and emergency providers who are able to care for all patients.
The Reimbursement Advocacy Firm (TRAF)
The Reimbursement Advocacy Firm (TRAF) helps providers keep their doors open, ensuring patient access to critical trauma and medically necessary care. TRAF redresses power inequities that exist between health plans and providers.
Our legislative voice and presence in the healthcare industry has allowed us to create a revolutionary division at the increasing demand of provider members who want a fresh alternative to the “conventional” collection agency.
|AUTHORITY IN FEDERAL AND STATE REIMBURSEMENT LAWS||YES||NO|
|REVIEWS CLAIMS FOR SUPPORTING CASES, STATUTES AND REGULATIONS||YES||NO|
|FIRST HAND EXPERIENCE DEALING WITH PROBLEMATIC PAYORS||YES||NO|
|CREATES APPEAL AND DEMAND LETTERS USING ADMINISTRATIVE AND CASE LAWS||YES||NO|
|FILES COMPLAINTS WITH REGULATORY AGENCIES TO REDRESS HEALTH PLAN VIOLATIONS||YES||NO|
|BEGINS COLLECTION PROCEDURES AGAINST PATIENT OR GUARANTOR IF CLAIM IS DENIED||NO||YES|
|PREPARES CORRECTIVE ACTION PLANS TO BRING PAYORS INTO FEDERAL AND STATE COMPLIANCE||YES||NO|
|INSTILLS PREVENTIVE MEASURES TO AVOID FUTURE IMPROPER DENIALS||YES||NO|
When it comes to reimbursement, the healthcare landscape can be perilous. But TRAF has the tools to show the way. With our nationwide experience, we can customize our enforcement campaigns for the laws in your state. The topics below sample the most urgent denials reported by our provider membership. As industry experts, we can address any denial trends that effect your facility.
Medical Necessity Denials
The payor denies healthcare services as medically unnecessary. Laws such as California’s Health and Safety Code § 1370.2 protect patients and providers from such adverse benefit determinations by requiring payors to ensure that all clinical issues are evaluated by personnel who are “competent to evaluate the specific clinical issues” presented, or to consult with an appropriately licensed provider who is competent. Furthermore, protections such as Health and Safety Code § 1367 (g) add plans “shall have the organizational and administrative capacity to provide services to subscribers and enrollees. The plan shall be able to demonstrate to the department that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management.”
The payor retrospectively rescinds authorization for treatment due to medical necessity, a pre-existing condition, untimely filing of the claim or appeal, or terminated coverage. Many states and federal jurisdictions have statutes such as California’s Health and Safety Code § 1371.8, which states a health care service plan that authorizes a specific type of treatment by a provider shall not rescind or modify this authorization after the provider renders the health care service in good faith and pursuant to the authorization for any reason, including, but not limited to, the plan’s subsequent rescission, cancellation, or modification of the enrollee’s or subscriber’s contract or the plan’s subsequent determination that it did not make an accurate determination of the enrollee’s or subscriber’s eligibility.
Emergency Services & Care
The patient receives treatment for an emergency medical condition, and the claim is denied as a non-emergent treatment. States like California affirm that “Emergency services and care shall be provided to any person requesting the services or care…for any condition in which the person is in danger of loss of life, or serious injury or illness…” (Health and Safety Code § 1317 (a).) Furthermore, California’s Health and Safety Code §1371.4(b) states “As long as federal or state law requires that emergency services and care be provided without first questioning the patient’s ability to pay, a health care service plan shall not require a provider to obtain authorization prior to the provision of emergency services and care necessary to stabilize the enrollee’s emergency medical condition.”
“Poststabilization care” means necessary medical care following stabilization of an emergency medical condition. Depending on the jurisdiction (State HMO or Federal MA Plan) a health care service plan must either authorize poststabilization services and care or arrange for the prompt transfer of the enrollee to another hospital within 30-60 minutes of the time the provider makes the initial telephone call. What happens if a patient cannot be safely discharged or transferred? Under most state laws and Medicare regulations, health plans are statutorily mandated to reimburse providers for poststabilization care when they fail to approve or disapprove a provider’s initial contact requesting authorization. Any failure to issue an authorization deems the services authorized and payment cannot be denied. (e.g. 42 CFR § 422.113 and CA Health and Safety Code § 1262.8 (d)(1).)
The payor denies a claim because of their deadline for filing a claim after patient discharge. According to State law, an insurer may not refuse to process a claim due solely to lack of timely filing unless the insurer can prove that it was substantially prejudiced by the late filing (Valley View Home of Beaumont., Inc. v. Department of Health Services (1983) 146 Cal.App.3d 161.) Our claims compliance auditors will affirm that late filing does not prejudice your company.
No Claim on File
The payor asserts they have not a received a claim form and denies or pends the claim until the insured provides a completed claim form. However, many states and jurisdictions across the nation have erected laws such as California’s Health and Safety Code § 1371, which states “If the claim or portion thereof is contested by the plan…the claimant shall be notified, in writing, that the claim is contested or denied, within 45 working days after receipt of the claim by the health care service plan.” These deadline requirements impress payors to maintain aggressive oversight of its claims tracking and claims processing department to ensure the continuous provision of quality healthcare to enrollees in emergency departments and vehicles. Failure to do so is often grounds to file a complaint with your jurisdiction’s regulatory agency.
Refund Requests on Authorized Services
The payor asks for a refund of a payment previously made on a claim. This often occurs after a retrospective review is conducted on a previously authorized claim and the payor discovers the patient was not covered. We challenge retroactive denials with the laws in your state, such laws such as California’s Health and Safety Code § 1371.8, which establishes that “A health care service plan that authorizes a specific type of treatment by a provider shall not rescind or modify this authorization after the provider renders the health care service in good faith and pursuant to the authorization for any reason, including, but not limited to, the plan’s subsequent rescission, cancellation, or modification of the enrollee’s or subscriber’s contract or the plan’s subsequent determination that it did not make an accurate determination of the enrollee’s or subscriber’s eligibility.”