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Re: HMO non par
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Steve Verno
Re: HMO non par
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Sep 15 05 12:13 PM
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You have the correct statute (641.31)(12). That statute says that an HMO, when establishing a policy for emergency care and services is required to pay 75% of "reasonable" charges up to the limit of the benefit.
Now, what is "reasonable"? The statutes do not define this. Florida pretty much allows the HMO to make this determination. But there is a light at the end of the tunnel.
Here is where everything changes. The magic word is ERISA!
and here is where I repeat myself:
1) You are not contracted with the HMO, the patient is contracted with the HMO. You are not a party to the HMO patient's contract.
2) The claim you send is not your claim. It is the patient's claim. The HMO receives the claim (and they could care less who sent it) and they process it based on the terms of the contract they have with their member.
3) Once payment of the benefit is made, the HMO no longer has responsibility.
4) The patient, not the HMO, is responsible to pay you for the services you rendered to the patient.
Now, under FS 641.3154, it implies that you, the provider are supposed to send the claim. However, if this is an ERISA plan, and the patient's contract says that the patient is to send the claim, how can Florida law override the contract which is under Federal jurisdiction?
FS 641.3154 says you cannot balance bill an HMO member. But it doesn't say anything about billing the HMO member from the beginning. Lets say your fee is $100 and the HMO paid $60. How do you know that the amount that was paid is correct, based on the contract with the member? What if the contract calls for the HMO to pay $100? This is where the HMO plays games with Florida's HMO law. If this is an ERISA plan, you are allowed to bill the member because under Title 29 CFR 2560-503-1, it is the member that must appeal their insurance company's adverse benefit determination and an adverse benefit determination is when the HMO pays less that 100% of the billed charges. Lets go further and say that the contract requires the patient to pay any amount above 80% of UCR and the HMO determines UCR, but the HMO paid 60% and then says that under Florida law you cannot bill the patient. Well, the contract with the member demands that pay the balance of the bill. How can Florida law override the contract that is under Federal Jurisdiction and prohibit the HMO member from abiding by their contract?
Lets say you bill the member. All the HMO can do is rant and rave and scream and tell the patient you cannot bill them and they don't have to pay. But the secret of ERISA is, under Title 29 USC 18, Sec. 1144a, it says ERISA supersedes any and all State Laws as it pertains to an employee health benefit that is under the jurisdiction of ERISA. If the HMO wants to do anything, they have to file a complaint with the Department of Health, Medical Quality Assurance Division. Once they do this, the MQA will ask for additional info. Once they get that, then they can investigate. Once they do this, you show them documentation that this is an ERISA plan (so make sure it is an ERISA plan when you do bill the member. Easiest way to find out is to send a letter to the patient asking them to provide you with a copy of the plan, asking them if the employer is providing the health benefit and who that employer is. ). If it is BCBS and Aetna, go to Availity.com and print out the benefit page which will show the employer sponsor. Once you have this, you can show the MQA, Title 29 USC 18, you can show Title 29 CFR 2560-503-1, and you can show that this is an ERISA plan where your billing of the member is to enforce their ERISA rights. Once the MQA sees this, then they will have to make a decision as to whether Florida Law has jurisdiction or ERISA. If they find in your favor, it will open the floodgates.
But, think of this, what can the HMO do to you for billing their ERISA member?
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Association News
Medical Billing & Coding Education from the MAB
Continuing Education
Management Advice and Training
Questions Asked More Than Once
Help Wanted - Billing and Coding
Non Billing Talk
The Venting Area (Clean posts please)
Medical Coding and Billing News
Fraud and Abuse
Health Insurance - Provider Contracting
ERISA
Tricare
Workers' Compensation
General Medical Billing Questions
Appeals
Accounts Receivables (A/R)
Refunds
Auto Accident Issues
Medisoft Technical Support
Medical Software Technical Support Questions Other than Medisoft. No Investigation Questions!
General Medical Coding Forum
CPT Coding Questions
HCPCS Coding Questions
ICD-9-CM Coding Questions
Evaluation & Management Coding Questions
Acupuncture Billing and Coding
Ambulance Coding and Billing
Cardiology Coding and Billing
Chiropractic Coding and Billing
Dental Billing and Coding
DME Coding and Billing
Emergency Department Coding and Billing
Family Practice Coding and Billing
Hospital Inpatient and Outpatient Coding
Hospital Billing, Appeals and Collections
Internal Medicine Coding and Billing
Laboratory Coding and Billing
Ophthalmology Coding and Billing
OB-GYN Coding and Billing
Pain Management Coding and Billing
Pediatric Coding and Billing
Podiatry Coding and Billing
Physical Therapy Coding and Billing
Psychiatry Coding and Billing
Radiology Coding and Billing
Surgery Coding and Billing
Neurology Coding and Billing
Urgent Care Coding and Billing
Provider Compliance
Billing Center Compliance
HIPAA
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