The two primary businesses that make money from the handling of medical bills in the workers’ compensation system are PPO networks and repricing companies. These groups earn fees by helping the insurance companies to pay less than the full amount of medical charges.

I will always remember a vice president for a national insurance company admitting to me, “We don’t care what the doctor charges; we refuse to pay a bill in full no matter the charge.”  I have reviewed thousands and thousands of billings, and I can tell you that this unusually revealing statement is most definitely true.

Here is how it works:  The insurance company receives a medical provider’s bill, and sends it on to a repricing company for review and handling. The repricing company first seeks to determine whether any PPO networks have secured contracts from the provider permitting the application of discounted fee schedules to the bill. If so, those schedules are applied, and the provider will receive a payment along with an Explanation of Review that will inform the provider that its bill has been reduced in accordance with the signed PPO contract.

But if the repricing service finds no PPO contracts in effect for a particular provider, the bill is still never paid in full. Instead, the repricing service will apply certain reduction standards of their own devise, then issue partial payment along with an Explanation of Review that lists the criteria applied in that particular case.

The repricing service earns a commission or a line item audit fee based on the amount it successfully saves the insurance company off the bill. If a PPO network’s contract played a key role, the network company will also earn a commission.

In Virginia, PPO network contracts will generally be enforced. But in the absence of such contracts, many of the discounts claimed by repricing services can be defeated by medical providers if they should choose to challenge the underpayments through the Virginia Workers’ Compensation Commission’s medical provider claims process.

At Meyer, Goergen & Marrs, our experience has been that PPO network contracts in the workers compensation industry are a notoriously bad bargain for medical providers. Once “out of network”, a provider can successfully challenge repricing companies’ bill slashing and greatly improve their realization rates on their workers’ compensation billings. Let us show you how we can work with your billing staff to get you the payments to which you are entitled and improve your practice’s financial performance.

Professionals:

Rick Yannitello
Brad Marrs

I don’t need an attorney, I can handle it myself!

Rarely can anyone get away with self representation. Insurance companies require unrepresented victims to play by their rules. Representing yourself will likely just result in simply losing time and money.

I can’t afford an attorney!

Most personal injury attorneys work on a “contingency fee” basis. This means that the attorney only receives a fee if there is a settlement or favorable verdict. If there is no recovery, there is no attorney’s fee.

I will save money by not going to an attorney!

Many victims (or families of victims) will likely only lose money by not seeking proper representation. Victims or families of victims are not familiar with settlement and verdict histories for that type of case in the venue most likely favorable to them. Victims or families of victims have no experience in negotiating with trained adjusters or attorneys in these types of cases. Victims or families of victims are not familiar with the multiple avenues of recovery available to them. Victims or families of victims are not aware of the liens that may have to be satisfied with the proceeds (including health insurance, workers compensation, Medicare and Medicaid). Victims or families of victims are not aware of the repercussions the settlement may have on public benefits.

I can handle it for now and get an attorney later if I really need one.

Early hiring of an attorney will preserve your right to pursue an action and protect you. A personal injury attorney can make sure that your case is properly investigated early – including locating and interviewing witnesses and the police officer, as well as photographing the scene, vehicle and injuries (in the case of a motor vehicle accident). A personal injury attorney can prevent the unnecessary release of your life-long medical and employment records that most insurance companies try to obtain prior to litigation. A personal injury attorney will prevent the insurance company from obtaining a recorded statement outside of litigation. A personal injury attorney will protect a victim or victim’s family from the premature settlement of a claim, making every effort to include every element of damages the victim is entitled to recover.

I don’t need an attorney since I was not at fault!

Whereas you may think you were not at fault, the other side will work diligently to prove you were at least partially at fault. In Virginia, if they can prove you were even partially at fault, you are prohibited from any recovery.

The insurance company says I don’t need an attorney – that they will make sure I am fully compensated!

Sadly, many defendants and insurance adjusters take advantage of kind, injured, upset or grieving victims. Adjusters are trained to say what you want to hear and what will allow them to settle the case for the lowest amount possible. Don’t ever forget that insurance companies are businesses and that paying out claims takes away from their profit!

If you have any questions about personal injury or wrongful death, contact one of the personal injury attorneys at MGM Law for a free consultation.

Attorneys:
K. Ruppert Beirne
David G. Browne

Right now, Congress is considering reducing reimbursements to providers due to federal budget constraints. For many providers, participation in Medicare is a matter of professional duty, with care being provided partly as a public service, given the knowledge that payments will be woefully below true value. If reimbursement rates are cut still more, the cost of participation may rise so high that more and more providers opt out of the federal systems by declining [Medicare or Medicaid?] patients.

Each provider will need to make its own decision as to whether or not to continue participating in any system that requires the provider to work below cost. That approach has always applied to worker’s comp as well, but due to the often direct relationship between CMS rates and worker’s comp reimbursements, providers need to be alert to the possible need to make a business decision this year.

That decision need not be to stop treating worker’s comp patients.  Rather, it would merely require the provider to exit all workers’ comp networks, treating comp patients only on an “out of network” basis.  In those situations, Virginia law mandates payment according to “prevailing community rates” or PCR – rates that are determined according to statistical evidence reviewed on a case-by-case basis, without regard for CMS payment schedules.
Any medical provider needing help with its worker’s compensation network relationships, or just with getting fairly paid on worker’s compensation billings, should contact attorney Brad Marrs, or worker’s comp consultant Rick Yannitello.

Click here to read more about Revenue Solutions for Healthcare Providers

The networks sell membership by promising greater utilization by payors – an increase in patient volume that, in our experience, never materializes.  What the employers and their insurers do care about, and what influences their utilization decisions most, is getting injured workers back to work through quality care.  The “Box O’ Contracts” offered to payors by the networks is something they are happy to take advantage of if available, but seldom influences the choice of medical provider up front.

Many medical providers have no recollection of how they got into worker’s comp networks in the first place, much less what they are to be paid, or how they might go about exiting the networks.  The layers of red tape, redundancy, inefficiency, and misinformation cause medical providers to spend four times as much time on a worker’s compensation claim compared to a non-injury claim.  Frankly, the networks prey on the sheer difficulty of dealing with them to hope that the provider simply never bothers to challenge its handling of billings.

At Meyer, Goergen & Marrs, in addition to helping providers to recover just payment for their professional services, we help to identify network contracts that may date back decades as well.  This allows our clients to determine if the network is actually performing in the manner it promised, or how they can effectively terminate their network relationships for their long term benefit.  Instead of being one more contracted provider in the box, our clients can focus on providing high quality care, and then let us work effectively for them in assuring that they are paid as the law requires.

Any medical provider needing help with its worker’s compensation network relationships, or just with getting fairly paid on worker’s compensation billings, should contact attorney Brad Marrs, or worker’s comp consultant Rick Yannitello.

Click here to read more about Revenue Solutions for Healthcare Providers

You Got Hurt

It seems like the most obvious answer, but if you were in an accident that was not your fault and were injured, it’s probably a good idea to get a personal injury lawyer. In the case of car accidents the insurance company for the party that hit you may contact you right after the accident to settle as quickly as possible and ask you to sign releases, which could prevent you from getting the best settlement to compensate you for the injuries sustained. Hiring a personal injury attorney means you’ll have somebody in your corner who is interested in what is best for you, knows your rights and will advocate on your behalf.

Who’s at Fault is in Dispute

If there’s ever a debate about who’s at fault for an accident, it’s a good idea to hire a personal injury attorney. Having somebody with knowledge of the law can help you make sure everything possible is being done to investigate and protect your interest and allocate the blame where it belongs. Paying for something when you’re not at fault is adding insult to injury.

The Other Driver is Uninsured or Underinsured

Even if there’s no debate about the other driver’s fault, if they don’t have any insurance or don’t have enough to compensate you for your injuries, getting a lawyer is advisable to help explore every avenue for recovery, whether investigating the assets of the defendant or combing through the many forms of insurance that may be available. A personal injury attorney will know what you should be entitled to and how to go about properly pursuing your claim.

Any Time You’re Not Sure of Your Rights

Any time you’re in any kind of accident and there’s an injured party, be it yourself or somebody else, there’s something to be said for at least consulting with a personal injury attorney to see if you need their services. The hiring of an attorney in these situations prevents you and your loved ones from being taken advantage of by an insurance company or deprived of your rights.

Attorneys:

K. Ruppert Beirne
David G. Browne

Rather than speeding from one person to the next, this structured networking event focuses on truly connecting with others. You will have the opportunity to make fresh connections, discover new resources, and uncover prospects and leads. Bring plenty of business cards and get ready to connect! Click here to register.

The Supreme Court’s decision to tackle the constitutionality of Obama’s Healthcare reform is not a surprise, as the reform has been the subject of passionate litigation in courts across the entire country. The federal courts have been split on the constitutional validity of the healthcare reform. It was here in Virginia that Judge Henry E. Hudson of the Richmond Federal District Court previously struck down the individual mandate portion of the health care reform bill, finding it to be in violation of the United States Constitution. (Click here to read our blog “Obama’s Healthcare Plans Ride to the US Supreme Court Gets a Jumpstart in Virginia” posted December 15, 2010.)

The Supreme Court will likely hear arguments in the spring of 2012 and issue a ruling in the months prior to the election next November. All eyes will be on the Supreme Court as the Court’s decision will not only impact businesses and individuals, but may also have an immense impact on the upcoming presidential election.

Attorneys:
Patrick Henry
Brad Marrs

Let’s talk first about the workers’ compensation system.

In Virginia any employer with 3 or more employees is required to carry workers compensation insurance. The policy rates are determined by the industry in which the employer operates, and its history with prior claims. When a worker is injured in the course of employment, the injured party is provided both medical benefits and reimbursement for income lost.

Virginia’s workers’ compensation system does affect the business performance of any medical practice providing treatment for work-induced injuries. Providers need to be savvy to the rules of our state’s system in order to assure that they are paid the full amounts to which they are entitled under the law.

Unlike many other states, Virginia does not specify a fee schedule for provider services. The state workers’ compensation law requires only that insurers pay either the amount billed or, if less, the “prevailing community rate.”  Unless the provider signs a contract with a workers’ compensation claims processing network that specifies particular rates of payment, the insurance company has the burden of proving that amounts billed exceed “prevailing community rates.”  In the absence of a signed contract or proof of overcharging, the Virginia Workers’ Compensation Commission commonly orders insurers to pay providers the full amount of their billings.

Sometimes a medical provider in one state may find itself treating a patient with a worker’s compensation claim pending in another state. Medical providers are to follow the compensation act in which the patient was injured. Virginia-based providers treating patients injured in accidents in other states may be surprised to learn that their charges will be compared to fee schedules adopted by law in, e.g., West Virginia, Tennessee, Maryland, Pennsylvania, or Washington DC. Some of these states even allow for management of the course of care by parties other than the treating physician.

On the other hand, out-of-state providers treating patients with claims in Virginia’s system will not face managed care decisions imposed from outside the doctor-patient relationship. Nor will they be subject to the application of rigid fee schedules; instead, they will be able to rely upon the presumptive validity of their own rates and bills.

There are other work injury programs that affect medical providers such as Longshore Harbor Workers Act, Jones Maritime Act, Federal Employers Liability Act, and Department of Labor/Office of Workers Compensation Programs. More to come; stay tuned.

Professionals:

Rick Yannitello
Brad Marrs

Certain life situations, however, often galvanize us to consider writing a will, including:

• an exotic vacation requiring travel by ship or plane;
• the birth of a child, when parents begin pondering who will act as substitute guardians should both parents meet their untimely demise; and
• the failing health of an older person.

But while certain milestone events may lead you to think about a will, you should not wait for one to begin careful planning.

Even those motivated to write a will sometimes, because of cost, either shelve the idea or attempt to make it a “do-it-yourself” project by using an online form or commercial computer software. If you have made your own will, the lawyers at MGM Law will be happy to review your homemade will without cost. Based on our experience so far, however, we have never seen such a will that did everything the maker wanted it to do. Sometimes the self-made wills are legally invalid and, on occasion, they can create significant unintended and costly issues.

MGM is working to alleviate the uncertainty of estate planning costs by offering in many cases a flat fee for the preparation of will, advance medical directive, and power of attorney documents. The flat fee for all three documents for an individual leaving an estate to children is $750.00; it is $1,000.00 for a married couple naming the surviving spouse as primary beneficiary, with their joint children as contingent beneficiaries.

Please note that the flat fees generally do not apply to clients who: desire estate tax planning; have children by prior marriages; have a number of beneficiaries other than their spouse and/or children; have a “special needs” beneficiary; change their minds requiring re-drafts of documents; or have other legal needs in addition to wills, advance medical directives, and power of attorney documents.

Having an effective will in place, along with an advance medical directive and power of attorney documents, can bring you peace of mind. Whatever your estate planning needs, MGM’s lawyers will help you create a plan that is right for you and your family.

Attorneys:

Pete Goergen
Joe Hall

The NLRA applies to union and non-union employers, however, certain employers and employees are excluded from NLRA’s requirements and protections. For example the NLRA does not apply to federal and state government employers, and the NLRA does not apply to independent contractor or agricultural laborer employees. But even with these exemptions, the vast majority of private sector employers remain subject to the NLRA. If an employer or employee is unsure if the NLRA applies to their respective business or employment, they should act cautiously and confer with an attorney. The new notice requirement is only applicable to those employers subject to the NLRA.

The notice of rights sign, which will be made available at no charge to the employers, will state “that employees have the right to act together to improve wages and working conditions, to form, join and assist a union, to bargain collectively with their employer, and to refrain from any of these activities.”  Click here to see NLRB, Board issues Final Rule to require posting of NLRA rights.

This rule has been the subject of great debate and public comment, with many employers opposing the rule, arguing that it unnecessarily encourages and fosters unionization.  Proponents of the rule counter that the notice merely ensures that employees are aware of the rights already afforded to them by law.  Regardless of the underlying policy, the rule will become in effect on November 14 and employers must be sure to comply.

As an employer, it is essential to be fully cognizant of the NLRA and the rules imposed by the NLRB.  As evidenced by the notice of rights rule, the regulations and requirements evolve over time.  As such, an employer should take efforts to remain informed of these changes and should consult an attorney with any questions.

Attorneys:

Patrick Henry