Learning Objectives

• The truth regarding commercial insurance assignment and what it does not mean
• Dispel the myths regarding Out of Network coverages with Medicare Part C Plans
• Misleading statements regarding Timely Filing Limits by all commercial plans
• Why the Timely Appeal Periods are not what they have been taught they are
• The only instance (which is very rare) that a carrier can recoup on claims legally
• How the federal laws protect the patient and the medical provider
• The fact that pre-authorizations are not required nearly as often as providers believe
• A vital fact that gives the providers much more power with carriers than they thought
• The most effective way to deal with anyone at insurance carriers or TPA lying to them
• Illegal tactics used by many carriers to perform recoupments, & how they are illegal
• Proper responses when carriers send the checks to the patient & how to fight it
• Why complying with record requests may be opening clinics up to HIPAA violations
• Carrier time limits on paying and on denying claims – it’s not what you think
• How to make Part C plans cover all that Part B does – it’s the law!

Areas Covered in the Session

• When You Mark Accept Assignment on Claim Form
• If You Are Out of Network provider, Do Commercial Carriers Have to Send You the Checks?
• For Medicare Part C Plans, If You Are Out of Network, Are They Required to Send You the Checks?
• For Commercial Carrier Plans Provided by Employers, Who Set Your Timely Filing Limit?
• For Medicare Part C Plans: Who set Your Timely Filing Limit?
• For ERISA or PPACA Plans, What Is the Minimum Appeal Period?
• If You Are Out of Network with A Medicare Part C Plans, How Much Are They Required to Pay You on The Claim?
• When Can a Commercial Insurance Company Make the Doctor Refund Money Paid on A Claim?
• What Is ERISA?
• Employment Compensation
• When Is It an ERISA Claim?
• How Does ERISA Help Me with My Insurance Claims?
• Provider Agreement:
• Patient’s Policy
• How Do I See Patient’s Policy?
• Carrier Requires Pre-Authorization When Pre-Authorization Is Not Required Per the Policy
• Language In Every SPD on Every Policy
• Stop Recoupments
• ERISA: Are There any Timely Limits?
• 1140 Is A Civil Crime – But 1141 Is Criminal
• Who Can They Recoup From?
• What If They Already Recouped – What Can We Do?
• Carrier Time Limits on ERISA
• What Is a CFR?
• CMS Plan on Having All Medicare Patients Switched Over to Part C Plans By 2030
• Lie about MA Plan: “We Don’t Cover RPM” – Medicare Part C Must Cover What Part B Does
• MAOs Must Pay Within 30 Days
• PPACA & Medicare Filing Time
• The Record Requests
• CMS – Limits Medical Record
• HIPAA Minimum Necessary
• Government Definition Entity
• HIPAA Protections
• Are You Helping MAO’s Break the Law?
• Medicare Advantage CMS Contact

Suggested Attendees

• Healthcare CEOs
• Healthcare CFOs
• Healthcare COOs
• Clinic CXOs
• RCM Executives
• Hospital Administrators
• Claims Staff
• Appeal Specialists
• Office Managers
• Billing Staff and Companies
• Physicians and Other Providers
• Healthcare Consultants
• Compliance Officers
• Practice Manager
• In and Out of Network Providers
• Providers Office Staff
• Hospitals and Facilities
• Insurance Companies
• Healthcare Attorneys

About the Presenter