Matt Lewis Law - Collection Strategies For Liability Medical Necessity Disputes Feb 2011


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This will be a compliance issue so train your staff now and keep your cash in your pocket

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A LOC can be asked and answered in 21 days, negating the duty to pay

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Matt Lewis Rogers, Booker & Lewis Collection Strategies For Providers Faced With Liability & Medical Necessity Disputes - 2011

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New IR Distribution Requirements Effective March 1, 2011 New DWC-69 DWC-69 and narrative must be faxed to Austin Central at (512) 490-1047 Designated Doctors must also fax DWC-73

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Liability Disputes Compensability Extent Of Injury Entitlement To Benefits

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New DD Rules Provide Collections Stick Effective February 1, 2011 Carrier shall pay all benefits, including medical benefits, in accordance with the DD report Upon receipt of DD report, carrier has 21 days to pay medical benefits

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Carrier must reprocess all medical bills previously denied for reasons inconsistent with the findings of the DD Rule 127.10(h)

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What To Do: Fax a copy of the favorable DD report to the adjuster and keep the fax receipt Do not make a demand for payment or otherwise prompt the adjuster to quickly initiate dispute resolution Wait 21 days Demand payment immediately and file complaint against carrier and adjuster with DWC for failure to timely pay a medical bill

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Sub-Claims Establish sub-claimant status by showing a benefit was delivered and reimbursement was denied (a bill and an EOB) Providers may pursue compensability and extent of injury issues to a benefit review conference

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If the claimant participates in the dispute resolution process the provider is able to appear and negotiate, give testimony, evidence and argument If the claimant is not participating, several prerequisites apply (Rule 140.6)

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Prerequisites No prior written agreements between the claimant and carrier or DWC decision resolving the dispute Must give written notice to the claimant

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Written Notice Of: Intent to pursue the claim Warning that the resulting decision could be binding against claimant Contact info for the OIEC

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Collect Old Write-Offs! This method can be used to collect on aged files, many years old Rule 133.307(c) allows for filing MDR up to 60 days once a related compensability, extent of injury or liability issue is resolved Great idea for large unpaid bills like chronic pain management or work hardening that were denied as treatment not related to the compensable injury

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Medical Necessity Deviating from ODG IRO process Medical CCH Judicial Review

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Documenting Exceptions To ODG Appendix D of ODG First, use the help desk to find the correct section of ODG for the requested treatment You can actually suggest ODG updates

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What To Document Extenuating circumstances that warrant the treatment Co-morbidities Objective signs of functional improvement for treatment conducted so far

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Measurable goals and progress points expected from additional treatment Any additional supporting evidence

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Most important criteria are the co-morbidities and documented functional improvement from prior treatment

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Dispute Process When preauthorization is denied, must submit request for reconsideration within 15 days If denied again, IRO request must be filed within 45 days (Form LHL-009) If IRO is adverse, 20 days to request a CCH Network appeals go to judicial review

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Medical CCH Tips Introduce into evidence all applicable medical records, especially those that address Appendix D deviation requirements Do not rely only on your own testimony of medical necessity Offer medical studies and journal articles supporting your position

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Offer other treatment guidelines that recommend the requested treatment Play up co-morbidities - they make each patient different from the averages Provide supporting studies about the effect of the co-morbidity on recovery - do not rely only on your testimony

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Summary: Collection Strategies For Providers Faced With Liability & Medical Necessity Disputes - 2011 . Liability Disputes includes Compensability, Extent Of Injury and Entitlement To Benefits.Dispute Process is aplicable when preauthorization is denied, must submit request for reconsideration within 15 days,if denied again, IRO request must be filed within 45 days (Form LHL-009), if IRO is adverse, 20 days to request a CCH, network appeals go to judicial review. For More Info Visit

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