DISCLAIMER: RevAssurance services do not constitute legal advice or legal consultation and do not establish an attorney-client relationship. The determination of the need for legal services and the choice of legal counsel are the sole responsibility of the Provider. You are encouraged to seek independent legal advice at your sole discretion.

ASK YOURSELF:

• Did we verify eligibility? IF SO, WHAT DATE?
• Did the plan make negligent misrepresentation of the patient’s eligibility?
• Did the plan deny maternity coverage for no authorization?
• Is the plan refusing to comply with 45 CFR §146.130(a)?

The objective is to bring the plan into compliance with federal law designed to benefit the public and protect our financial viability.

Hi, my name is ____________________, this call may be recorded for compliance purposes, I’m calling to investigate a possible violation of 45 CFR §146.130(a); can I give you a patient ID#?

1. RESPONSES TO REBUTTALS.

“THE CLAIM HAS BEEN DENIED AS NOT AUTHORIZED.”

Pursuant to 45 CFR §146.130(a):

4) (i) In general. A plan or issuer is prohibited from requiring that a physician or other health care provider obtain authorization from the plan or issuer for prescribing the hospital length of stay specified in paragraph (a)(1) of this section. (See also paragraphs (b)(2) and (c)(3) of this section for rules and examples regarding other authorization and certain notice requirements.)

Further, under 45 CFR §146.130(a), {PAYOR} has a duty to provide all Medicare-covered services and is mandated by federal law to cover these services. 45 CFR §146.130(a) states:

(1) General rule. Except as provided in paragraph (a)(5) of this section, a group health plan, or a health insurance issuer offering group health insurance coverage, that provides benefits for a hospital length of stay in connection with childbirth for a mother or her newborn may not restrict benefits for the stay to less than –

(i) 48 hours following a vaginal delivery; or

(ii) 96 hours following a delivery by cesarean section.

(2) When stay begins –

(i) Delivery in a hospital. If delivery occurs in a hospital, the hospital length of stay for the mother or newborn child begins at the time of delivery (or in the case of multiple births, at the time of the last delivery).

(ii) Delivery outside a hospital. If delivery occurs outside a hospital, the hospital length of stay begins at the time the mother or newborn is admitted as a hospital inpatient in connection with childbirth. The determination of whether an admission is in connection with childbirth is a medical decision to be made by the attending provider.

I urge you to adjudicate this claim today to bring your plan back into compliance.  As mandated by the above-cited statutory law, we request that you reevaluate your position in this matter and urge you to take appropriate steps, to rectify the problem and demonstrate your good faith in this matter.

I need to read you the following disclaimer: Your failure to reimburse {FACILITY NAME} is a serious matter and violates patient rights and federal regulation designed to benefit the public (UNTIMELY PAYMENT HAS A NEGATIVE EFFECT ON LEVEL OF CARE).

The provision of continuous quality health care in our region depends on {FACILITY NAME} receiving payment for medically necessary services provided to patients.

Failure to comply with this telephonic notification of non-compliance to the applicable code section may result in audit, investigation and the assessment of sanction and penalties by CMS.

When is your next check run?  I need to track the compliance of your plan in regards to this matter.