Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
Issue link: http://outpatientsurgery.uberflip.com/i/519657
J U N E 2 0 1 5 O U T P A T I E N TS U R G E R Y. N E T 6 1 • Different plans, different options. The litigation process as it relates to state-regu- lated plans versus ERISA plans differs in a few ways. If the patient has a state- regulated plan, facilities have more options available when it comes to litigation, such as being able to file in state court and applying traditional bad faith laws. ERISA-governed plans, however, are subject to federal laws, which can be more limited. The lawsuit is filed in federal court and you often don't get a trial at all. If you do, there is no jury trial, and discovery — the process of gathering evi- dence — is very limited, if not prohibited altogether. I'll hit on other important distinctions at the conference. • Are you in or out? It's also important to understand how being in-network versus out-of-network affects your rights when it comes to billing litigation. If you're an in-network provider, you can claim for breach of your provider agreement if the payor breaks your contract. You can also rely on "prompt pay" laws, which set a deadline on when claims must be paid. On the other hand, out-of-network providers must be more vigilant about securing assignment of benefits forms from patients and ensuring those forms are broad in the rights they convey. • Protect against overpayment litigation. There has been an increase in overpayment or recoupment litigation brought on by payors. Since claims are submitted elec- tronically, health insurance carriers can audit and analyze payment trends more easily than ever before. Because payors can reach back 3 years and recoup claims that were allegedly "overpaid," it's important to know that upticks in your reimbursements may result in subsequent attempts at recoupment. However, just because a payor claims it overpaid doesn't mean you have to immediately roll over and repay. It's critical to know your rights and best prac- tices in overpayment scenarios. • Leaving a paper trail. Having well-documented processes and procedures for