Subrogation recoveries for Medicare Advantage plans

In February, my colleague Liz Longo was featured as a webinar speaker for the National Association of Subrogation Professionals (NASP) on the topic “Medicare Advantage Plan Recoveries: Best Practices and Shifting Legal Tides.”  This topic has been evolving for more than 10 years as litigation and case law have disputed over the issue of whether the private cause of action for double damages under the Medicare Secondary Payer (“MSP”) Act provides Medicare Advantage (“MA”) Plans with the right to bring suit against primary payers.  The early rulings generally held that the secondary payer rights and recourses granted to the government under the MSP are different and do not apply to MA plans under the federal statute. As such, the only recourse available to MA Plans was to pursue reimbursement of those conditional payments through contract-based action in state courts.

The most significant hurdle is overcoming the fundamental misconception that MA Plans are private insurers.  In order to do so, MA Plans must be “all in” in the sense that they must adhere to all of the rules and regulations imposed upon an MA Plan. That being said, MA Plans must be sure to operate with caution in order to avoid compliance pitfalls.  As such, MA Plans must notify members of appeals rights, track grievances, maintain records of coverage investigations, and stay up-to-date on DX code directives in the CMS MSP Manual.

MA Plans must also utilize effective subrogation pursuit and recovery strategies. For example, ICD-10 and external property and casualty databases are very effective methods of leveraging technology for member outreach. The MA Plan may also track chronic conditions or review MSP files made available monthly by CMS. In doing so, MA Plans will address a primary concern, which is to avoid member abrasion during the identification and investigation processes.

If you would like to hear more about our point of view on MA Plan recoveries and best legal practices for subrogation, you can listen to our recorded webinar, available in its entirety for NASP members by clicking here.

 

Eddie PallSubrogation recoveries for Medicare Advantage plans
read more

Post-conference wrapup: 2015 NASP Conference

As a first-time attendee at the 2015 National Association of Subrogation Professionals (NASP) Conference, I wasn’t sure what to expect, but the education sessions, networking and entertainment were insightful and valuable.  So much so, that I’m already planning for the 2016 event.  Before sessions began, the NASP board of directors grabbed everyone’s attention with an amazing magician and illusionist, Mike Super.  Mike’s performance included members from the crowd and included everything from voodoo dolls to defying gravity.

After the kick-off entertainment, it was time to get down to business.  A variety of sessions were held throughout the day covering a breadth of subrogation topics including health, auto, property, product liability, or workers’ compensation.  I spent most of my time on the health subrogation track where multiple topics of interest were addressed including private causes of action by an Medicare Advantage Organizations under the Secondary Payer Act, ERISA analysis, and aggregate claims analysis (mass tort claims).

Day two featured a particularly interesting keynote address from Michele Stuart of JAG Investigations, an investigation specialist and expert in cyber-sleuthing. Her presentation was alarming and fascinating as she showed us how vulnerable our social media activity makes us to criminal activity and walked us through steps we can take to protect ourselves. She also showed us how we could use cyber-sleuthing strategies to inform our subrogation investigations. It is clearly a powerful and accessible tool that can be valuable for case identification and investigation.

Between the education sessions and ample networking time, I consider the NASP 2015 to be a huge success and look forward to working with some fresh ideas for my own subrogation clients and sharing insights with the Discovery Health Partners subrogation team.  Thanks to the NASP team for a great show and to the Discovery Health Partners team for their work and efforts on the show floor.

 

Eddie PallPost-conference wrapup: 2015 NASP Conference
read more

Subrogation ebook 2014

Best practices for maximum results

With the right strategies in place, increased subrogation recoveries are within any health plan’s reach.eBook: Next-Generation Subrogation Solutions

A health plan’s successful recovery of injury-related claims depends upon a fine-tuned and optimized subrogation process. Additionally, it’s important that plans continue to manage all areas of recovery, including emerging opportunities like Mass Tort, which, with the right technology and expertise can be an effective way to add to the bottom line.

Download your copy of this exclusive 28-page ebook and learn how next-generation solutions can help your subrogation recovery:

  • Identifying the best cases for recovery
  • Optimizing the recovery process workflow
  • Measuring and managing program performance

Just complete the quick download request form on the right for immediate access.

 

 

 

Access and download this exclusive 28-page eBook today.

 

 

Discovery Health PartnersSubrogation ebook 2014
read more

Maximizing your mass tort recoveries

Joint replacement surgery is fairly common in the United States, with more than 285,000 hip replacement surgeries every year[1]. However, if that new hip turns out to be defective—causing further pain or weakening of the joints—this routine hospital procedure could become subject to the complexities of mass tort litigation.

What is mass tort?

Mass tort occurs when a faulty drug or device harms a large number of people, such as a hip replacement that causes tissue and bone death, or a diabetes drug that is linked to bladder cancer. In a mass tort case, each plaintiff files an individual claim resulting from distinct damages and each plaintiff receives his own trial. Mass tort relies on some of the same processes and procedures as subrogation to recover payments. However, due to the complexity of mass tort cases, not every health payer has the technology, expertise, or resources to devote to pursuing mass tort.

Cost recovery opportunity

While mass tort litigation is certainly complex and resource-draining for health plans to pursue, it represents a substantial cost recovery opportunity for health plans, with potentially millions of dollars in legal settlements at stake.

Discovery Health Partners Mass Tort solution

Discovery Health Partners offers a solution to maximize mass tort recoveries with a unique process model that drives measurably better results. Built on the pillars of accurate identification, proactive legal expertise, dashboard visibility, and compliance with regulatory agencies, our solution has the potential to recover millions of dollars for our partner health plans.

Identification

Identifying members who received medical care associated with mass torts requires powerful data mining and advanced analytics capabilities. Each case involves a new set of indicators, and requires distinct analytic models. Data is drawn from claims, diagnostic and procedure codes, as well as medical and legal records for more accurate identification with fewer false positives.

Legal expertise

Mass tort recoveries require a detailed understanding of complex legal processes and jurisdictions, which some health plans don’t have available to them in-house. Discovery Health Partners has expert in-house legal counsel with a deep knowledge of mass tort and established processes for litigating these claims, which often fall into overlapping jurisdictions. Using advanced state-of-the-art case management software, our legal team proactively tracks cases and pursues recoveries using this systematic approach.

Visibility and compliance

Like any complex process, optimizing mass tort recoveries requires visibility into trends, exceptions and outliers, and performance indicators. Discovery Health Partners’ full-service dashboard provides visibility into your mass tort inventory with detailed reporting. With this transparency, senior management can track trends and cases for more accurate forecasting. It also provides internal and external reporting insights that meet all compliance requirements.

Results with Discovery Health Partners

The best approach to mass tort in today’s post-healthcare reform era is proactive, systematic, and programmatic. Discovery Health Partners has implemented these best practices with our current clients at a rate of 100% satisfaction. We are the leading provider of mass tort solutions, with millions in successful recoveries for our clients, and we are ready to help your health plan identify, pursue, and maximize tort recoveries.

 

 

[1] American Academy of Orthopaedic Surgeons, 2014 – http://orthoinfo.aaos.org/topic.cfm?topic=a00377

 

 

 

 

 

 

 

Discovery Health PartnersMaximizing your mass tort recoveries
read more

Next-generation subrogation solutions: measuring your subrogation program

As the old saying goes, “You can’t improve what you don’t measure.” Imagine you are a student taking a test and never knowing your grade. It’s nearly impossible to strategize a plan for improvement if you are unaware of your current performance.

This same principle applies to subrogation cases. Analytics are essential to evaluating the performance and effectiveness of any subrogation program. Armed with meaningful data and metrics, organizations can better analyze performance and make future strategic decisions.

Transparency and benchmarking

To make the necessary improvements, you need to know how your subrogation program stacks up against others. How do you know if your program is performing above average, in the middle, or just plain poorly? Transparency in data, both internally and from vendors, will reveal insights about your subrogation performance within the industry as a whole.

Benchmarking also gives subrogation professionals some guideposts on where their programmatic weaknesses and strengths may lie. What is needed now is a cultural shift by vendors and health plans to increase operational transparency and provide real benchmarking. Health plans should have full access on a 24/7 basis to all case details housed in their vendors’ case management applications, including incoming and outgoing correspondence, telephone calls, activities and diaries of activity.

Real-time dashboards, such as the one offered by Discovery Health Partners, provide on-demand information and metrics that illustrate the current status of your subrogation inventory. Dashboards are able to integrate information from multiple vendors as well as hybrid models, providing the user with the fullest and most accurate picture.

Examples of data that should always be available to the health plan include information on daily, monthly, and annual recoveries; case inventory data; and vendor performance metrics. This data should be sortable by client, funding source, accident type, and specific date range. Reports should be easy to run and offered in a user-friendly format that will help business users understand subrogation performance.

Closed case data can be particularly instrumental in demonstrating why you are recovering on some cases, and not recovering on others. Again, a dashboard system allows the user to sort by cases that have been and have not been recovered and the reasons why the plan is and is not recovering. Next, that data must be able to be filtered by claim type, plan type and other relevant recovery factors. The ability to analyze your data will allow you to evaluate subrogation program performance and then make strategic decisions regarding future program improvements.

Conclusion

Discovery Health Partners has seen dramatic results using the next-generation subrogation solutions outlined in our series. Discovery Health Partners’ subrogation solutions have helped health plans across the country increase recoveries by millions of dollars within a year of implementation. With these best practices, Discovery Health Partners leads the path forward for health plans to improve subrogation recovery rates and ultimately contain costs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discovery Health PartnersNext-generation subrogation solutions: measuring your subrogation program
read more

Next-generation subrogation solutions: optimizing your subrogation solutions

Once you have identified which subrogation cases have recovery potential and which do not, it’s time to make sure you are optimizing program performance in three key areas:

  • Platform – leveraging technology and automation to improve results
  • Process – evaluating recovery workflows to ensure efficiency is maximized by leveraging available technology
  • People – recruiting and maintaining a united and coordinated team of people

Optimizing your platform

Leveraging the most current technology and automated systems will yield more recoveries with less cost and fewer resources.

Cloud technology

Cloud technology offers a next-generation solution for loading and processing claims data, with cloud-based data storage and on-demand added capacity. Not only is cloud storage scalable and much less expensive than physical data storage, it allows for easy and mass loading of claims data and execution of claims processing. Given the ability to load multiple data files at the same time, health plans can quickly pursue reimbursement, a crucial part of maximizing recoveries. In addition, cloud-based storage providers offer encrypted HIPAA compliant instances in compliance with the Security Rule.

Case management software

Powerful, flexible case management software solutions are critical to improving your subrogation process. Subrogation processes involve large amounts of mail, including questionnaires, letters, and other correspondence between multiple parties. It is important to have the right software to track and manage your cases.

One component of an effective case management software solution includes integration of two-dimensional bar codes on all correspondence. Investigation questionnaires are typically the first step in a subrogation investigation. If those questionnaires and follow-up letters are bar-coded, they can be tracked more effectively. Bar codes also reduce the risk of a HIPAA breach by preventing questionnaires from being associated with the wrong case.

Other examples include: introduction of a library of template-based letters that can be selected and generated systematically; integration of fax functionality that allows the user to fax letters directly from the application; creation of time stamped activity description that records every activity undertaken on a case; and integration of plan language within the application so the user can access the applicable plan information on a case by case basis.

Optimizing your process

An automated workflow that is proactive, predictive, and intuitive is the foundation of next-generation subrogation solutions. It is important that both your case management tools and workflow have the flexibility to adjust to changing conditions and process improvements.

Ideally, an automated process will trigger a “next” event whenever an event occurs, i.e., if a notice of lien or reimbursement rights is sent, the system should automatically schedule an event to follow up on that notice. Today’s best automated systems remove the need for manual scheduling. This frees up your employees and resources to focus on more meaningful tasks in the process.

ISO queries

Taking a broad look at what’s working—and what’s not working—can help to streamline your process. You may find that the traditional first step of sending a questionnaire isn’t the most effective for your investigation. Some populations are slow to respond to mailings and they often go unanswered. Bypassing the questionnaire and initiating your investigation with an automated ISO query may be a better option.

It is also important to look at the cost-effectiveness of an ISO query vs. a more traditional mailing. User interface tools, like the one used by Discovery Health Partners, let you manage the selection and cost of ISO queries. An automated and user-selectable dashboard sorts information by various claim categories or by the age of the case. Analytics and data tracking tools give you a full picture of cases that are a “hit” or “miss” with the query. A close examination of this data lets you determine the overall effectiveness of your ISO automation.

Proactivity is a must in all phases of the subrogation process. When members don’t respond to mailings, outbound calling becomes a critical step in obtaining information. Leveraging all possible investigative tools like court documents, police reports, and ambulance run reports can help identify cases that have recovery potential. Legal oversight and attorney involvement should be present from the start of an investigation to provide ongoing communication and counsel on any changes in laws.

Optimizing your people

Technology isn’t enough when it comes to optimizing your recovery process. You need the right people to interpret and synthesize your data. In short, your people need to be able to recognize a viable subrogation case when it is in front of them. This analytical outlook coupled with a high level of comfort on the phone and a soft touch with people is a good mix for a subrogation investigator. They will know the right questions to ask, have the skill to analyze the data, and possess the initiative to follow up on those compelling cases.

Identifying the right candidates is just the first step. Training, continuing education, and workplace incentives are crucial to maintaining your team. Workplace incentives can go a long way toward boosting morale for a united, coordinated staff who will contribute to the success of your plan.

Measurement

Rising health care costs are a concern to us all. Successful subrogation can help contain those costs, but the entire process—from the platform to the people—needs to be optimized so that resources are used wisely and effectively. A highly optimized subrogation process results in better tracking of metrics and data, and an uptick in recovered losses. For more on metrics and measurement, read Part III of our “Next-generation subrogation solutions” series.

 

 

 

 

 

 

 

 

 

 

 

Discovery Health PartnersNext-generation subrogation solutions: optimizing your subrogation solutions
read more

Next-generation subrogation solutions: Identifying opportunities

No one wants to leave money on the table. But that’s often what happens when health plans don’t recover payments for claims that are someone else’s financial responsibility. A health plan’s successful recovery of injury-related claims depends upon a fine-tuned and optimized subrogation process. In our three-part series, “Next-generation subrogation solutions,” we offer effective strategies for the identification, optimization, and measurement of the subrogation process to help your health plan contain costs and maximize results.

Identifying the right subrogation cases is the first step in recovering injury-related payments made by the health plan. Many of the currently utilized subrogation identification practices are outdated and unrefined, resulting in more or missed cases, but not the right cases to maximize results. There are several best practices that can help health plans accurately identify these cases, without wasting resources on unnecessary investigations. Implementation of these best practices, which leverage today’s technology, predictive data analytics and scoring, can truly optimize your subrogation results.

“If you don’t identify the cases, you can’t recover or cost-avoid,” Liz Longo, Discovery Health Partners General Counsel, said in a recent webinar. “It’s a delicate balance between identifying too many cases, which results in false positives or non-recoverable cases, and identifying too few cases, which results in missed opportunities.”

Fine-tuning your identification process can help you achieve optimum accuracy in pinpointing the right subrogation cases, resulting in a cost savings to your bottom line.

 

Best practice: scoring and predictive analytics

Current practice: subjective, static

Diagnosis code lists have long been the starting point for uncovering potential subrogation cases. However, these lists of codes tend to be subjective and not frequently reviewed. Scoring and predictive analytics can help you uncover which cases will drive your recoveries. Predictive analytics means that there is a continuing analysis of the codes used (diagnosis, procedure, revenue codes), in connection with varying demographics (age, location, presence of other medical conditions), compared against the data on recoveries achieved. When looking at all of this together, you can identify and constantly refine which combinations are more likely than not to result in a recovery. The goal is to learn from the data then use what you learn.

Looking at diagnosis codes in isolation from other claims information often misses the mark. Looking at diagnosis codes along with demographic information will identify the relationships that lead to recoveries and allow the plan to prioritize recovery efforts.

For example, fractured femur and fractured ankle and foot codes are typically included in the subjective and static identification lists commonly used. Fractured femurs are very common in older populations and more often than not are not related to any accident or injury for which there is a recovery source. Similarly, fractured ankles and foot bones are common among diabetics unrelated to any accident or injury. By utilizing scoring and predictive analytics, there will be a fine tuning and continuous sharpening of which fractured femur, foot and ankle codes, in combination with other codes and demographics, are likely to yield a recovery and which codes are not.

Plans want to make sure that those relationships and trends that result in recoveries are continuously identified and that subrogation identification is refined based on what has been learned to drive improved accuracy.

 

Best practice: deeper dive analysis

Current practice: limited review

It is critical that plans leverage all available claims data in the identification process and not just consider one or two diagnosis codes. A deep dive into all available claims data reveals important details that might be overlooked in a more limited review. Diagnosis codes must be reviewed along with other codes, including procedure codes and revenue codes. If you only look at the first code on a diagnosis claim, you will likely miss valuable identification information.

For example, “E” codes describe external causes of injury in the place where those occurred (i.e., a car accident on a highway). Because “E” codes are not revenue-generating codes, they usually never appear as the first code on a claim. You might see that a member has sustained a sprained neck by looking at the first diagnosis code on a claim. Without further review of the second or third code, you might overlook the code that indicates that the sprained neck was sustained as a result of a car accident.

The importance of analyzing all available claims data is further illustrated in the case of mass torts. Identification of mass torts is very different from traditional subrogation cases and requires a unique analysis and identification process.

With respect to the failed hip and knee devices (Stryker, Depuy, Biomet, etc.), diagnosis codes alone are not selective enough to identify those revisions or other medical conditions that may be caused by a failed or defective device. Procedure codes along with diagnosis and revenue codes are the only effective way, solely from a data mining perspective, to identify these opportunities, making a deeper dive analysis of all claims data a critical step.

 

Best practice: table driven and flexible

Current practice: hard-coded and not customizable

One size does not fit all for purposes of identification. Different populations and demographics require different identification. Therefore, it is important that your identification be table driven and flexible.

In current practices, identification is often hard-coded and not customizable. This rigidity results in the inability of the plan to adjust its identification criteria for a select group or population leading to over or under identification. Oftentimes, ASO groups may have identification needs different from other populations such as excluding or flagging the identification of medical malpractice cases. Without table driven identification, such select identification exclusion is not possible.

As another example, firefighter populations illustrate the need for flexible and table driven identification. Many states have enacted cancer, cardiac and lung presumption laws, meaning that these conditions are presumed to be work-related diseases. Accordingly, flexibility in identification is required to pinpoint these cancers, cardiac and lung conditions that we would actively seek to avoid identifying in other populations. Your identification needs to be flexible enough to accommodate the differing identification needs of varying populations.

 

Best practice: scoring and tracking

Current Practice: ignores chronic condition

Another critical component of an effective identification process is the ability to account for and track member chronic conditions. When a member or other source indicates to the plan or the plan’s vendor that the member has a chronic condition, e.g., a bad back, knee, shoulder, that condition for that member should be flagged. Going forward, then, that condition, alone, should not be reinvestigated in the future.

This chronic condition scoring is a win-win for everyone. It results in reduced member abrasion by minimizing unnecessary member outreach and saving costs associated with needless investigations. This identification and tracking of chronic conditions substantially reduces cost and waste for the plan.

 

Beyond identification

Using these innovative subrogation best practices for identification, Discovery Health Partners has significantly improved the subrogation process to deliver better recoveries. The first step to these recoveries is accurate identification, but the process doesn’t stop there.

The next installment of our three part-series on “Next-generation subrogation solutions” will look at the next two steps in subrogation recovery process: optimization and measurement.

 

 

 

 

 

 

 

 

 

 

Discovery Health PartnersNext-generation subrogation solutions: Identifying opportunities
read more

Discovery Health Partners hosts webinar on next-gen subrogation

Second in series of webinars to address health payer payment integrity topics

ITASCA, IL (May 27, 2014) –Discovery Health Partners announces a webinar on June 4 that addresses best practices for maximizing subrogation recoveries as part of an overall cost containment solution for health payers. Entitled “Next Generation Subrogation Solutions,” the webinar will be led by veteran subrogation expert Elizabeth Longo, general counsel, Discovery Health Partners. Longo will share best practices in next generation subrogation technologies, including how advanced data mining and improved analytics can increase transparency and maximize recoveries.

The webinar will also address the challenges that prevent plans from maximizing their subrogation potential such as identifying the right cases for pursuit, optimizing the recovery process workflow, and evaluating and managing program performance.

“At a time when plans are struggling to reduce costs and increase revenue, many payers are not realizing the full financial benefit of their subrogation programs, which can significantly impact the bottom line,” said Longo. “Our session will shed light on the obstacles facing health payers today and identify effective subrogation solutions that can help drive considerable increased recoveries while reducing costs.”

The June 4 webinar is scheduled at 12p Central/1p Eastern. Interested health payers can sign up at https://www.discoveryhealthpartners.com/subrogation/webinar/

The session will cover:

  • How advanced data mining can pinpoint the best recovery opportunities
  • Which subrogation processes have evolved as the industry advances
  • How to leverage advanced analytics to improve performance
  • What new tools are available to provide transparency into what is a black-box process
  • New technologies for case management and workflow
  • How to build the right team for top performance

“Health payers will benefit from our insights into powerful new subrogation technologies and best practices, illustrated with real-world examples of our work for leading health plans. We have a proven track record of helping plans improve their subrogation results and generate millions in recoveries,” said Longo. “We will cite case studies showing how we helped our clients leverage better data mining and analytics, streamline business processes, and drive measurably improved results.”

As part of the set of solutions Discovery Health Partners offers to payers looking for advanced payment integrity platforms, a new microsite is available at https://www.discoveryhealthpartners.com/subrogation-resources/

This is the second in a series of webinars from Discovery Health Partners that focus on healthcare payment integrity topics. To sign up for future webinar alerts, visit https://www.discoveryhealthpartners.com/webinar-series/.

 

Additional information

To learn more about Discovery Health Partners and our solutions, please visit one of our resource pages or complete our contact request form to speak with a Business Development Director.

Discovery Health PartnersDiscovery Health Partners hosts webinar on next-gen subrogation
read more

Case Study: northeast community health plan cost containment success

DHP-CSImagine if you knew that $2 million of your company’s money was scattered across the streets outside your office. It’s a windy day, your staff is tied up at a training session, and you’re meeting with clients all afternoon. Would you let it blow away?

The truth is, health insurers all over the country are throwing away millions of dollars each year, either by not performing or underperforming critical cost containment measures, such as subrogation and coordination of benefits. See how one community health plan boosted its savings by millions in a matter of months.

Download Slides >>

 

 

 

 

 

 

 

 

Discovery Health PartnersCase Study: northeast community health plan cost containment success
read more