Briefing: The JAG’s Role in the Third Party Collections & Policy Date: 22 March 2007

1. Briefing: The JAG’s Role in the Third Party Collections & Policy Date: 22 March 2007 Time: 0800 - 0850

2. Objectives • Explain the legal office’s role in the UBO Claims programs, including policy and collections   • Explain the differences between civilian sector billing and collection rules, and how they may differ from, or impact the federal Third Party Collection Program (TPCP) (state prompt pay laws, etc.) • Explain when you should contact your legal office to discuss a payer issue • Review a few TPCP “issues” • Update on a variety of recent legal collection initiatives  

3. JAG’s Role • Policy • Issuing general policy on various issues surrounding the TPCP per our interpretation of the statute and regulation • Collections • Seeking payments on disputed claims from payers • Refunds • Recommending whether to issue a refund

4. Civilian Sector vs. DoD • Generally, the same billing and coding rules apply to MTFs • Use caution when deviating from a standard practice per the direction of an insurance company – and if you do, make sure you have the insurance company’s directive in writing!

5. Civilian Sector vs. DoD • State Prompt Pay laws • Sometimes they apply (e.g., timeframe for a payer to pay a “clean claim”) • Sometimes they do not (e.g., since there is a federal interest rate, state interest rates do not apply) • Employee Retirement Income Security Act (ERISA) • Health Insurance Portability and Accountability Act (HIPAA)

6. When To Call Your Legal Office • Call or transfer claims to your Regional Claims Settlement Office (RCSO) (or our office if necessary): • When you have spotted a payer trend/practice and the payer is not responding to your demands for payment • Anytime you’re not sure if a payment or denial is correct • Per the timeline and guidance issued from MEDCOM UBO (currently NLT 180 days from date of initial billing)

7. The PPO Issue • The “Preferred Provider Organization (PPO) provision” has expired • DoD needs statistics before they will try to revive it • MEDCOM UBO is developing a method to come up with statistics • So…what does this mean? • Payers will pay a lower percentage rate because the patient’s share will be higher • The percentage rate should be based on the billed rate, however – not a Usual, Customary & Reasonable or Blended Rate • Any “unusual” PPO issues that pop up – discuss with your legal office

8. Medicare Secondary Issue • 32 C.F.R. 220.3(c)(5) prohibits a payer from paying an amount that would be secondary to a non-existentMedicare payment … UNLESS the plan: • expressly disallows payment as the primary payer to all providers to whom payment would not be made under Medicare; AND • is otherwise in accordance with applicable law -Continued-

9. Medicare Secondary Issue • There are times when payers have to pay primary; e.g., it’s an employee group plan, and the policyholder (patient or spouse) is still working • If you receive a secondary payment, you need to do some homework and submit an appeal to the plan asking for additional information (if needed) • Refund requests: you don’t have to issue a refund on every claim that was paid primary in the past • There are legal arguments for keeping the overpayment (e.g., doctrine of laches – they waited too long to ask for it) • See your legal office if unsure of whether you need to issue a refund, especially if over 9 months since payment received

10. Settlement Authority • The MEDCOM Office of the Staff Judge Advocate and Regional Claims Settlement Offices (RCSOs) each have $100,000 termination/compromise authority per claim • The Department of Justice (DOJ) has to approve terminations/compromises on claims over that amount • This does not mean all claims must go to your legal office to be closed. Please see MEDCOM UBO closure codespreadsheet and guidance regarding which claims have to be forwarded

11. Recent Collection Initiatives • Medco • Resulted in over $2 million to DoD MTFs in 2005 and Dec 2006/Jan 2007 • Mailhandlers • Remittances did not clearly explain denial reason; follow-up revealed they were paying patients due to new software • Agreed to search for and re-process claims for all DoD MTFs

12. Recent Collection Initiatives • Humana • Paid $957/day instead of DRG • Great Plains RCSO is negotiating a settlement • Caremark • Modified two of their automation systems to print patient’s last name on explanation of benefits • Phone contact for eligibility and claim status info • Letter – not contracted to adjudicate government claims – MTF should contact plan and mail claim directly to plan • Letter – No longer processes paper claims for benefit plan – Caremark is not contracted to process paper claims for this plan – contact plan and mail claim to address as per plan

13. Summary • We’re from the JAG office, and we’re here to help!

14. Quiz • When should you call your legal office with a question? • Should you issue a refund every time a payer requests one? • When do claims need to be transferred to your legal office for resolution, if still in dispute?