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When Coordination of Benefits Becomes Uncoordinated

By Shirley La

Staff Attorney at Praxis Healthcare Solutions

What is “coordination of benefits?” Coordination of benefits is defined as “the practice of ensuring that insurance claims are not paid multiple times, when an enrollee is covered by two health plans at the same time” according to One insurance plan is considered the primary payer while the second insurance plan is defined as the secondary payer. The primary payer is billed first by a patient’s healthcare provider, followed by the secondary payer. The secondary payer usually pays a portion of the remaining cost. This concept seems simple enough but it is not uncommon for insurance companies to point the primary finger at each other.

The following scenarios can occur when a patient is insured by Medicare and another insurance carrier at the same time. A sixty-five-year-old patient is admitted to the hospital. The patient has Medicare and is also insured through their employer. The hospital bills Medicare as the primary payer under the good faith belief that Medicare is primary since the patient qualifies for Medicare because of their age. Medicare denies the claim stating that it is not primary payer, but the other insurance on file is the primary payer. In this scenario, Medicare is secondary only if the patient’s employer has more than twenty employees.

Now let us consider this slightly different scenario. A sixty-four-year-old patient has Medicare and private health insurance coverage through their place of employment. The sixty-four-year-old patient is eligible for Medicare because of a disability. The patient’s employer has more than twenty employees but fewer than one hundred employees. In this scenario, Medicare is primary. Why? When a patient is Medicare eligible because of a disability, Medicare is primary if the patient’s workplace employs fewer than one hundred people. Timely filing deadlines and the patient’s limited knowledge of their insurance plans add layers of complexity for you to address.

If we change the scenario to assume the patient’s employer has fewer than twenty employees and Medicare denies the claim stating Medicare is not the primary payer; the hospital is allowed to bill the private insurance. However, because the employer has less fewer than twenty employees the private insurance will likely deny under the assertion they are not the primary payer. In this scenario, Medicare is the primary payer because the patient’s workplace employs less than twenty people. To resolve the issue the patient must contact Medicare to update their coordination of benefits. The hospital cannot update coordination of benefits on behalf of a patient. While the hospital waits for the patient to update their coordination of benefits, the timely filing clock keeps ticking. Every insurance company has its own timeframe of when a claim is considered to be filed timely. If a claim is submitted past the timely filing deadline, it will be denied. A healthcare provider can dispute or appeal the denial, and in doing so, a healthcare provider must lay out its case of why the claim should not be denied for timely filing.

Coordination of benefits can become uncoordinated the moment a claim is billed to an insurance payer. It is imperative that healthcare providers verify eligibility and the billing order of payers before the claim goes out the door. Provider portals (e.g. Availity) are a good starting point and when in doubt, waiting on hold with a payer is a small price to pay compared to the time and cost involved with a denied claim.

Which Insurance Pays First? Retrieved from U.S. Centers for Medicare & Medicaid Services:


The Power of Why

By: David A. Blakeley, Esq.

Praxis Healthcare Solutions, Senior Attorney

Let’s face it. Those of us who call insurance payers on a daily basis quickly learn the scripts that the representatives are given to read to us. Before long, we feel that we could have both sides of the conversation all by ourselves. We know that, with a given denial in front of them, the insurance company representatives are going to say certain things and make certain recommendations.

Many times, these scripted conversations will in fact get us down the road toward account resolution, but it is in the exceptions where we can really make a difference in our AR inventory. We have to combat the tendency to simply re-enact these scripts on account after account. We should be looking for the exceptional accounts, the outliers. The most powerful tool we have to recognize those accounts is a healthy curiosity.

What we, as AR professionals, must always bear in mind is that there is always a reason why a claim is being denied. Yes, many times, that reason is perfectly obvious – the Care Management Department failed to provide notice of an inpatient admission, the claim has been pended for accident details, a claim is showing an excessive contractual adjustment. In each of these cases, the reason seems self-evident, but what we must not lose sight of is that in order for that denial to occur, there was a break down somewhere in the billing cycle. Where that breakdown occurred can make all the difference in overturning that denial. In short, it’s not enough to know what the denial is and submit an appeal; we must also know why there was a process failure that created that denial. Perhaps an example is in order.

I recently dealt with a situation where I noted that we had a cluster of claims that had been underpaid. I reviewed the appeals that the client sent to the payer on these different accounts and thought they were more than adequate. Indeed, the evidence submitted by our client was irrefutable; yet, the claims were coming back with the determination that they had been priced correctly. So, I called the payer with a simple question: If our client had submitted clear documentation that the agreed upon payment amount was X, and the insurer was paying Y, the why was there a discrepancy?

Of course, the first level account rep for the payer wanted to just send the claim back to reprocess. I could have followed the script and said “ok,” and followed up in a month. I would of course then have been told the claim was determined to have processed correctly. Instead, I asked the representative why the payer was not taking notice of the proof provided in the appeal. He didn’t know, but that question set me up to go through a chain of supervisors and managers until I found someone at the payer who also was curious about the answer to my question.

As it turned out, the DRG was assigned an incorrect weight in the payer’s system. The payer was sending the claim back through its pricing software, but the calculation was going to continue to be wrong, no matter how many times the claim went back through and no matter how much documentation was submitted. We were able to get the weight corrected and the claim reprocessed. It paid the expected allowed to the penny. It only took the curiosity of one provider advocate and one payer supervisor to solve the problem.

That is the power of Why. The Adjustment Reason Code is only the first step in understanding how to salvage a denied claim. We at Praxis always talk about identifying the Root Cause of the denial – where in the Revenue Cycle the failure occurred that caused the denial. But there is more to it. We also should seek to question why that failure occurred where it did. May your curiosity never fail.

Increase Your Hospital’s Revenue by Improving the Patient Experience

By: Brittany Coleman, Esq.

Praxis Healthcare Solutions, Staff Attorney

According to a new report from The Advisory Board Company, the average cost for a hospital to collect on claims has increased by 70 basis points of net patient revenue. The Advisory Board Company also found that the average 350-bed hospital has missed out on up to $22 million in revenue because it does not focus on improving revenue cycle performance. Increased collection expenses combined with potential cuts to Medicare and Medicaid hospital reimbursements if Congress and President Trump successfully repeal the Affordable Care Act, make it imperative for a hospital to maximize its revenue cycle.

An effective way to maximize your hospital’s revenue cycle is to focus on improving a patient’s experience and overall satisfaction with your hospital’s billing and financial processes.

  1. Have your financial representatives get to know the patient when he or she is scheduling his or her procedure.
  2. Focus on giving the patient a clear and concise billing statement. We all appreciate it when we know what our upfront costs will be for goods or services like groceries, car repairs, and cell phone bills. Your hospital should provide this same information to a patient regarding his or her anticipated out-of-pocket costs. Outlining patient responsibility for deductibles, coinsurance, co-payments, and non-covered costs in a clear and concise billing statement can help a patient better understand his or her financial responsibility for services he or she will receive from your hospital.
  3. Give patients payment options to fit his or her ability to pay and convenient methods to schedule and make payments on hospital services.
  4. Provide an option for a patient to consolidate expected out-of-pocket costs for other providers like radiologists, anesthesiologists, and admitting physicians onto one bill to help the patient manage and pay those costs.

Following these steps helps your hospital build a positive and durable relationship based on transparency, which can lead to increased revenue collections on patient out-of-pocket costs that make up the majority of bad debt for a hospital.


Ellison, A. & Gamble, M. (2017, July 07). How hospitals can improve revenue cycle performance: 4 key thoughts. Retrieved from Becker’s Hospital Review:

Hagland, M. (2017, July 05). Advisory Board Company Leader: Time to Rethink Revenue Cycle in the New Healthcare . Retrieved from Healthcare Informatics:

Masterson, L. (2017, June 28). Hospitals lose $22M on average because of revenue cycle issues, report finds. Retrieved from Healthcare Dive:

Minemyer, P. (2017, July 5). 4 revenue cycle management challenges for hospitals. Retrieved from Fierce Healthcare:

An ACA Update …Will there be a vote before the August recess?

By: Kristen Gurley, Esq.

Praxis Healthcare Solutions, Staff Attorney

While the GOP has made progress in efforts of repealing the Affordable Care Act (ACA), actual legislation to repeal the ACA has stalled. A vote on health care reform could happen as soon as mid-July depending on when Senate Republicans deliver a new bill to the Congressional Budget Office. Current plans are to deliver a new draft in the upcoming few days and then push for a vote before the August recess. Senate leaders recently announced plans to delay their recess by 2 weeks in attempts to finally repeal and replace the ACA before their long August recess.

The new bill is expected to add provisions to allow insurers to offer “bare-bones” policies that create cheaper alternatives for healthier consumers. However, some warn that these plans would raise costs for those who are not as healthy and leave many with plans that don’t really provide much coverage.[1] Moody’s Investors Service says Senate Republicans’ proposed healthcare bill, dubbed the Better Care Reconciliation Act of 2017 (BCRA), would negatively affect hospital finances by causing the uninsured rate to rise.[2] Some highlights from the BCRA that was recently released are: 1. Cuts to Medicaid by phasing out monies provided to expand federal-state Medicaid programs. 2. Ending penalties for people not buying insurance and larger employers not offering coverage. 3. Largely retaining the subsidies provided to help millions buy insurance (income based). 4. Blocking federal payments to Planned Parenthood. 5. Repealing or delaying tax boosts that helped pay for coverage for approximately 20 million more people, which would result in a tax decrease for higher income people, medical industry companies, and others. 6. Higher premiums for some people with pre-existing serious illnesses.[3]

Many major healthcare providers and advocacy groups fear the bill will destabilize insurance markets and leave many without coverage. Therefore, some lawmakers are vying for a limited bill which would include provisions to continue federal payments to insurers that help contain costs for lower-earning consumer and inducements to keep healthy people buying policies.[4] Former administrators at the Center of Medicare and Medicare Services have suggested that dropping the controversial Medicaid changes for now and considering them later would allow passing of the bill.[5] “Medicaid is too big, too complex, and too important of a program to restructure within this rapid timeframe. Separating reforms would allow focus on stabilizing the individual health insurance market.”[6]

Some lawmakers and President Donald Trump are even insisting to at minimum repeal now and replace later. President Trump tweeted recently that the ACA should be repealed even if the BCRA fails to pass. However, many are skeptic of repeal occurring without a replacement. Repealing the ACA without a replacement might be as much of a challenge as passage of the bill. [7] Doing so could leave more than 20 million Americans, who now have private health plans or Medicaid coverage under the ACA, without insurance and with no guarantee of any alternative coverage.[8]

The countdown is on to see if the Senate can present a bill that will satisfy the concerns of all sides of the Senate majority in order to gain the necessary votes. It will be interesting to see what provisions actually make it onto the bill that is expected to be presented to the CBO in the upcoming days. At minimum, the Trump administration is hopeful that a repeal can happen before the August recess. However, many disagree with repealing without replacing and skeptics believe that a consensus being reached within this short time frame is just not likely to happen.

[1] LA Times. (2017, July 10). Senate hopes to vote next week on Obamacare repeal, as Trump pressures Republicans to act. Retrieved July 12, 2017 from,

[2] Becker’s Review. (2017, June 23). Moody’s: Hospital uncompensated care costs will rise under proposed Senate bill. Retrieved June 23, 2017 from,

[3] H. R. 1628. Discussion Draft. (2017) Retrieved on June 22, 2017 from,

[4] CNBC. McConnell says a limited health-care bill is needed if Obamacare repeal dies. (2017, July 6). Retrieved July 8, 2017 from,

[5] JAMA. JAMA Forum: Reforming Medicaid. (2017, July 11). Retrieved July 12, 2017 from,

[6] Id.

[7] Becker’s Hospital Review. Trump encourages ACA repeal even if BCRA fails to pass. (2017, June 30). Retrieved on July 6, 2017 from,

[8] Washington Post. Trump’s latest idea: Senate could repeal Obamacare now and replace it later. (2017, June 30). Retrieved on July 6, 2017 from,


Learning from UnitedHealth Group’s Legal Debacle

By: Joyce Varughese, Esq.

Praxis Healthcare Solutions, Staff Attorney

UnitedHealth Group Inc., the nation’s largest Medicare Advantage Organization (MAO), has been under fire with allegations of overbilling Medicare since February 2017. The Justice Department of the United States filed a complaint against the major insurance conglomerate in May alleging that “United Health routinely combed through millions of patients’ medical charts searching for data it could use to make patients look sicker than they really were” in what the government deems a “strictly one-sided revenue generating program.”[1] It is paramount for health care facilities to comprehend the ins and outs of Medicare, especially in regards to the fundamentals of Medicare payments, to avoid a quandary with the federal government.

Traditional Medicare

The traditional Medicare program reimburses doctors directly for procedures they perform. Traditional Medicare members pay a monthly premium to the Centers for Medicare and Medicaid Services (C.M.S.), whether or not they visit a doctor. C.M.S. also receives funding from U.S. taxpayers. If members see a doctor, the doctor sends a copy of their medical report to C.M.S. to get paid and C.M.S. then pays the doctor. Traditional Medicare compensates doctors according to the procedures they perform, i.e. lab tests, scans, operations, etc.[2]

Medicare Advantage

With Medicare Advantage, the government contracts with for-profit insurers to manage health care policies and pays insurers a yearly fee for each member they enroll. Essentially, Medicare Advantage permits Medicare beneficiaries to obtain health care coverage from private insurers rather than from the government. Medicare Advantage members pay a monthly premium to C.M.S. and often a separate premium to a private insurance company. If members see a doctor, the doctor sends a copy of the medical report to the private insurer, who then pays the doctor. C.M.S. pays the private insurer a base rate for each member. If the private insurer tells C.M.S. that the member required treatment for certain conditions, then C.M.S. pays the insurer more. Per acting U.S. Attorney Sandra R. Brown for the Central District of California, “Medicare Advantage plans not only receive taxpayer-funded payments, but are intended for the health and welfare of the beneficiaries.”[3]

The Issue with Medicare Advantage

The government pays insurers a predetermined amount for each person they enroll in Medicare Advantage, rather than paying doctors and hospitals a fee for every service provided. In order to prevent insurers from only enrolling healthy people, the government agreed to pay them more for unhealthy enrollees. How much more depends on a complex “risk scoring” system established by Medicare.[4] Regrettably, some insurers are underhandedly profiting from the government’s respectable aim to assist those who need health care coverage. The government has alleged United Health benefited by $3 billion from 2010 to 2015 alone.[5] In essence, insurers benefit from having “sicker” members due to the larger payout. The Medicare Advantage model creates a perverse incentive to “exaggerate the health care costs for their enrollees.”[6]

What to Watch Out For 

Misrepresenting a patient’s health is civil fraud under the False Claims Act. Health care facilities must ensure they are not requesting obscure treatments and procedures or augmenting diagnoses for an increased payout. In the same way insurers benefit from adding diagnoses, providers also benefit, as they will be reimbursed at a higher rate. Your facility must avoid the enticing temptation to enhance patient charts and thereby claims to the insurers must be avoided at all costs. This is not to say providers should not ensure patients obtain the best treatment, as eluding appropriate treatment is another legal detriment in itself. It is only to caution opportunistic treatment and inaccurate billing for purposes of an inflated payment. The bottom line is to have a system in place to ensure claims are continuously audited and not being overbilled. For future reference, tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to the Department of Health and Human Services at 1-800-HHS-TIPS.[7]


[1] Affairs, U. D. (2017, May 2). United States Intervenes in False Claims Act lawsuit Against UnitedHealth Group Inc. for Mischarging the Medicare Advantage and Prescription Drug Programs. Retrieved from U.S. Department of Justice: 

[2] Services, U. C. (2017). How Original Medicare Works. Retrieved from U.S. Centers for Medicare & Medicaid        Services: medicare/how-original-medicare-works.html

[3] Id.

[4] Walsh, M. W. (2017, May 19). UnitedHealth Overbilled Medicare by Billions, U.S. Says in Suit. Retrieved from New York Times:


[5] Id.

[6] Affairs, U. D. (2017, May 2). United States Intervenes in False Claims Act lawsuit Against UnitedHealth Group Inc. for Mischarging the Medicare Advantage and Prescription Drug Programs. Retrieved from U.S. Department of Justice:

[7] Walsh, M. W. (2017, May 19). UnitedHealth Overbilled Medicare by Billions, U.S. Says in Suit. Retrieved from New York Times:


New Year Open Enrollment Challenges

Every year at this time, hiccups in your revenue stream may be compromised as patients change their insurance company or their current coverage may have updated policy changes that were not noticed by the beneficiary. This creates uncertainty and potentially costly oversights for the healthcare provider.

Many reasons may cause a breakdown in communicating their new insurance coverage or plan when the new year begins. Patients may not have understood changes to their plan or even basic information about their plan and/or fail to recognize the importance of giving their healthcare providers their updated insurance information. Often patients seeking care are experiencing a stressful time in their lives and these details can fall through the crack. Also, many times family members need to be involved in their acute and post-acute selections at which time they may also be unfamiliar with their loved one’s insurance coverage.

Knowing this is most likely to occur, it is very important that eligibility verification is properly done at the time of admission or when services are rendered. Using automated verification is often a successful approach for identifying verification by many providers. Work with your patient to ensure clarity and full understanding of any changes to their plans and emphasizing the importance of discussing changes in their coverage to their healthcare providers

2017 Medicare Inpatient Only Procedures

We all have experienced Medicare denials for procedures performed outpatient when they are on Medicare’s list for inpatient only. This seems counter intuitive at times, but the rules are followed and processes need to be put in place to prevent lost reimbursement. While best to have the inpatient order assigned before the procedure, Medicare now allows the inpatient order to be written before discharge. Also, please note that you may still send the patient home the same day, however, the physician order must reflect inpatient.

Below is a summary of 2017’s changes noted when compared to the 2016 listing:

The following procedures were removed due to a discontinued code (SI=D):

33400 Repair of aortic valve  DISCONTINUED CODE
33401 Valvuloplasty open   DISCONTINUED CODE
33403 Valvuloplasty w/cp bypass  DISCONTINUED CODE
35450 Repair arterial blockage  DISCONTINUED CODE
35452 Repair arterial blockage   DISCONTINUED CODE

The following procedures were removed from the list and may be performed outpatient:


0169T Place stereo cath brain
0281T Laa closure w/implant
22585 Additional spinal fusion
22840 Insert spine fixation device
22842 Insert spine fixation device
22845 Insert spine fixation device
22858 Second level cer diskectomy
27477 Surgery to stop leg growth
27485 Surgery to stop leg growth
31584 Treat larynx fracture
31587 Revision of larynx
33400 Repair of aortic valve
33401 Valvuloplasty open
33403 Valvuloplasty w/cp bypass
35450 Repair arterial blockage
35452 Repair arterial blockage
6164B Evasc prlng admn rx agnt 1st
6164C Evasc prlng admn rx agnt add

The following procedures were added to the inpatient only list:

0451T Insj/rplcmt aortic ventr sys
0452T Insj/rplcmt dev vasc seal
0455T Remvl aortic ventr cmpl sys
0456T Remvl aortic dev vasc seal
0459T Relocaj rplcmt aortic ventr
0461T Repos aortic contrpulsj dev
33340 Perq clsr tcat l atr apndge
33390 Valvuloplasty aortic valve
33391 Valvuloplasty aortic valve
61645 Perq art m-thrombect &/nfs
61650 Evasc prlng admn rx agnt 1st
61651 Evasc prlng admn rx agnt add

And, the following procedures are the same, however, a slightly different code: 

2017 2016
33477 Implant tcat pulm vlv perq 3347A Implant tcat pulm vlv perq
54438 Replantation of penis 5443B Replantation of penis


Improving Patient Identification: A Joint Commission Safety Goal

Often when we think of problems with patient identify, we think of stolen identification. While this can and does happen, there are other ramifications more common that result from lack of having the correct patient information. If individuals are registered under the wrong patient or even wrong account, test results may not be readily found that may adversely affect patient safety because the patient may not receive appropriate and/or timely treatment. Financial inefficiency may also result.

The two most common patient identification errors are duplicate medical records and overlays. A duplicate medical record occurs when a single patient is associated with more than one medical record. An overlay occurs when one patient’s record is overwritten with data from another patient record which creates a combined, inaccurate record. American Health Information Management Association (AHIMA) reports that on average , the duplicate medical record rate is between 8-12%. And they state that approximately 40% of all records have blank or default values in one of the key data fields of first name, last name, date of birth, gender of Social Security Number. The healthcare industry experts report that the average estimated cost associated with a duplicate record can be as much as $1,000 per record, much less the potential for patient dissatisfaction and potential safety hazard that may occur.

Registration errors are common and special efforts from the front end are occurring to assist with minimizing the opportunity for human error. The use of biometric technologies is also emerging as an an effective positive patient identification solution.