Health plans are unlocking the power of ICD-10 codes and using modern technologies to identify and track the progress of cases to maximize recoveries when plan members have been reimbursed twice for injuries caused by liable third parties, Elizabeth Longo, general counsel for Discovery Health Partners, explained.
Unlock the Power of ICD-10
Using data mining and analytics to find exactly which cases should be pursued is easier than ever. More cases is not the goal; the point is to find the right cases, Longo said. If the plan fails to do this, the plan will miss recoveries and waste resources. Plans want to avoid chasing after false leads, but they do want to avoid missing important opportunities that could restore substantial funds, she noted.
The ICD-10 (the coding system health care providers use to report diagnoses, symptoms and procedures) is of tremendous utility to subrogation/reimbursement efforts, because it is so much more detailed than ICD-9.
Often plans refer to a list of diagnosis codes that tend to relate to the best cases.
New levels of detail in ICD-10 codes give plans important new abilities to see whether an injury can be associated with a recovery opportunity. For example, the new code book contains 2,400 variations of femoral fractures, and with that kind of detail — and with the help of predictive analytics, the plan can separate innocuous situations from recoverable incidents. In the ICD-10 code itself, you can locate information on the nature of the incident, including: the part of the body that was injured; the kind of accident; whether the accident was transport-related; the mode of transport; whether the victim was a driver or passenger; and what the vehicle collided with, Longo said.
Extension codes can indicate whether the plan member was at fault in the accident. Such codes also can tell the plan the kind of payer it will be opposing in the process: for example, Med-Pay, personal injury protection or under-insured motorist coverage, she said.
ICD-10 codes also tell the plan about services performed: when the member first presented with providers; continuing treatment he or she needed to repair the injuries; and treatment for complications directly connected to the injury. ICD-10 even gives plans a better chance of separating out pre-existing chronic conditions from treatment directly relating to the injury. Not accounting for chronic conditions results in investigating claims that will not be recoverable. Best practice results in opening cases for injuries that resulted exclusively from the accident.
Don’t Wait and Hope
Investigation should not be a letter campaign, sitting back, waiting and hoping the patient will respond. Low member response rates guarantee that such a strategy will not work.
Very often money is dispensed on first-come-first-served basis, and that reality does not allow for a passive approach. So Longo said that a proactive approach is imperative, including: investigating; leveraging external databases; making phone calls directly to the member; accessing ambulance report data; and doing court docket searches.
An additional solution involves contacting everybody involved in the case — not just the plan member’s personal injury lawyer to put them on notice that a plan lien will be asserted on the proceeds of eventual litigation.
And the in-house team working on the case also needs full information. For example, it needs a thorough understanding of the sources of potential reimbursement (Med-Pay, No-fault, UIM.)
Laws and Jurisdictions
If your subrogation team members don’t understand the interplay of laws, plan funding type and jurisdiction, as early as possible, unpleasant surprises could result, she said.
Team members who know the impact of plan funding, policy language on recoveries and the state laws governing recoveries will enable the legal staff to be proactive, and save resources as the case is pursued.
Team members must have logical and critical thinking, because the extent of the claim that can be asserted depends on the circumstances of the case. They also should not be easily intimidated by attorneys and insurance adjusters; they should know the plan’s rights and should have updated training, especially in privacy and security, she said.
Measuring Outcomes
When measuring the subrogation team’s performance, it’s a mistake to just look at the dollar amount of recoveries and the number of cases. It’s a better idea to take into account how hard the case was, and how thorough the work had to be to bring it to fruition, according to Longo. For example, cases on behalf of Medicare and Medicaid plans are easier because plan rights are stronger (because they rely on special federal laws to defend government money) and more clearly spelled out. On the other hand, commercial cases have more variables, for example, because they might involve, or rely on, state law.
Technology and Tools
Technology should be used to optimize the recovery process and measure how well the subrogation program is performing.
A good tool for the recovery process is cloud technology, she said. Cloud storage servers enable users to quickly upload claims and run identification processes. They are scalable, meaning their capacity can be quickly and cheaply expanded. Furthermore, Congress recently proclaimed that they are business associates so now they are covered under HIPAA’s privacy law, Longo said.
Cases are better managed by automating with digital technologies. For example, imaging technology enables plans to digitize all incoming and outgoing correspondence. Bar coding on investigation letters or questionnaires enables those documents to be automatically associated with the case upon their return. Software can create an automatic time stamp on every activity for each case along the line. Automated recordstrigger updates every time a document is added to or subtracted from a case, when a party is called or receives a letter; in sum, every move in the case gets a timed and dated record. Then software can create a detailed activity report, which will be more efficient and accurate than gathering case activity by hand.
She recommended auto-generated correspondence, including investigation letters when cases are created and standardized documentation creation at other key phases of the case. Automated case assignments are recommended so that depending on the case, certain experts get certain kinds of cases depending on whether plans are self-funded or fully insured; or commercial plans versus Medicare/Medicaid.
Automated reminders also can help the plan not fail to meet important deadlines. The subrogation department may want to wait 30 days after making an information request to receive a reply, so when the initial letter goes out, an action item is automatically created to follow up with the other side if no response is received in that time. Likewise, if the plan has been asked for information and a reply is due within 30 days, automated reminders can prevent deadlines from being missed.
Longo also recommended getting certified for data security using a third-party reviewer of policies, and taking out cyber insurance coverage for security breaches and the cost of consumer notification in the event of a data breach.
Transparency and Quality Control
Full access to cases and internal auditing drives better results and quality, even though it might be hard for team members and leaders to admit the shortcomings that are revealed. “Dashboard” technology leads the way, including real-time access to progress and recoveries, metrics showing team and program performance, records on how quickly cases are moved along and settlement amounts.