Question: I have a case where the hospital has a claim that needs to be submitted to Medicaid for payment. However, since the hospital knows that there is a liable third party, they are refusing to submit the claim to Medicaid. How can I force the hospital billing office to submit the claim for payment? – FL Attorney
Answer: In this instance, the provider has the right to go either way, so there is no real avenue to “force” a provider to bill Medicaid for services. Under Medicaid’s provider agreement, the hospital has the right to bill all other insurers first, with Medicaid being the final payer. On the other hand, Medicaid has the right to subrogate for payments made when a third party is responsible.
Medicaid as Final Payer – Why the Provider can bill liable insurer: FL Statute 409.907(3)(f) – Medicaid Provider Agreement (3) The provider agreement developed by the agency, in addition to the requirements specified in subsections (1) and (2), shall require the provider to: (more…)
Quick tips that can move your settlement to the Head of the Class!
A – Allocation: When in the process of negotiating a settlement and determining the allocation of proceeds, be mindful of any outstanding lien obligations. Some plans may have a right to recover from the full value of the settlement if an allocation does not protect their interest.
B – Bargaining with a provider or recovery agent can be worthwhile if there is a clear understanding of the strength or weakness of their right of recovery. Make them an offer they can’t refuse!
C – Call! Regular communication is necessary, especially when resolving with Medicare, Mediaid or the Military Health Plans. Remember, the squeaky wheel gets the oil!
D – Delegate: When the task of Lien Resolution becomes to overwhelming, delegate this aspect of case management to the PROs! Lien Settlement Solutions offers programs that meet all of your lien resolution needs. Call us at (877)907- LIEN to speak to one of our representatives! (more…)
Dear Synergy;
I’ve got a settlement and an 18 y/o client whose mother works for the federal government. All the medical bills appear to have been paid by the mother’s private insurance company, but I suppose that they may be the administrator. This is an Anti Subrogation state, but we assume that FEHBA plans are preempted. We have received no notice from the FEHBA or Private Insurer plans about any sort of subrogation interest. Have you been down this road before? – Confused in the Carolinas
In reviewing FEHBA subrogation, it generally preempts state law and is not beholden to ERISA law in which North Carolina is an Anti Subrogation state for some insured plans. I’ve been looking for any type of loophole where NC’s anti subrogation can be can be argued for a FEHB plan, but everything I’ve found is to the contrary. The strength of the right of recovery in a FEHBA plan lies in the specific description within the plan. I looked through a few plans to get an idea on how NC FEHBA plans are written. Specifically, I reviewed the BCBS of NC FEHBA Standard and Basic Operation plan for 2009 to get an idea of what the plan language may look like in this situation. According to the 2009 plan, it is the responsibility of the beneficiary to notify BCBS of any claim made against another party for compensation of an illness or injury where BCBS has made payment. According to their plan language, they are entitled to full recovery, and not subject to reduction for procurement. However it does express a willingness to grant a reduction at their discretion. It was not specified if the incident occurred in 2009, you would need to review the plan document for that year of enrollment. Hope this helps! Have a lien question? Ask us! Send your question to info@synergysettlements.com.