AUTHORIZED REPRESENTATIVE Issues for Hospitals & ASCs & COVID Patients Covered by Self Funded Employer Health Benefit Plans

Hospitals and ASCs across the nation are at risk for payments for COVID patients covered under ERISA and Taft Hartley self funded health benefit programs. In today's self-study lesson, I discuss the mechanics of the AUTHORIZED REPRESENTATIVE appointment in contrast with ASSIGNMENT of BENEFITS. This is one topic I cover in my Managed Care Contracting Master Classes (that will resume in September if we are allowed to resume live events.)

ABOUT THE AUTHOR:

Dr Maria Todd is the Director of Business Development at St George Surgical Center, and the author of 23 books on healthcare business administration topics, including: The Managed Care Contracting Handbook 2nd edition (3rd edition out soon), The Physician Employment Contract Handbook, 2nd edition, and the Handbook of Medical Tourism Program Development (2nd edition out soon) and the Employers Guide to Medical Tourism Benefit Design (out soon), and Launching a Robotic Service Line (out soon) published by Informa's CRC Productivity Press.

She is the group leader for The Managed Care Contracting Group here on LinkedIn, with over 11,000 members. When not in her part time role at SGSC, she works as a private healthcare business consultant, as she has for the past 40+ years. Her career spans from working as an OR nurse, an ASC administrator and hospital revenue cycle manager, a health law paralegal and mediator, and the director of provider contracting for a large national HMO brand.

WHAT YOU NEED TO DO RIGHT NOW!

Without a whole bunch of back story that you can learn when it is convenient to do so, right now you'll need a designation form that the patient or responsible guardian signs that states the following:

HOSPITAL NAME (LETTERHEAD WILL SUFFICE)

PATIENT's NAME, ADDRESS, PHONE, MR#

Designation of Authorized Representative

I ________________, do hereby designate the above named provider to the full extent permissible under the Employee Retirement Income Security Act of 1974 ("ERISA") as provided in 29 CFR 2560-503-1(b)4, to otherwise act on my behalf to pursue claims and exercise all rights connected with my employee health care benefit plan, with respect to any medical or other health care expense(s) incurred as a result of the services I receive from the above-named provider.

These rights include all rights to act on my behalf with respect to all initial determinations on my claims, to pursue appeals of benefit determinations under my plan(s), to obtain records, and to claim on my behalf such medical or other healthcare service benefits, insurance or health care benefit plan plan documents, reimbursement policy(s) procedure(s) or other information requested that I would normally be entitled, and to pursue any other applicable remedies.

Obtain a dated, witnessed signature and notation of the relationship of the parties and keep in the signed original on file as well as a scanned copy to send to the TPA or Plan Administrator listed in the plan's IRS Form 5500 so your revenue management team can do anything they need to do to file claims, appeal denials and challenge short paid claims.

IRS Form 5500 is publicly available on request under Freedom of Information Act. Don't accept any excuses or requirements that you need a special Auth Rep form. This happens often and it is simply a tactic to throw you off task or delay payment or appeal timeframes. Tell them "no we don't" in a polite but assertive manner.

Also a few other last minute pointers:

• Get this formed signed for ER patients and COVID testing patients just as you do when you formally admit after triage and EMTALA requirements have been met.
• Remember, most state laws require payment for emergency services by non-contracted providers at 100% of billed charges. It isn't your problem that they didn't negotiate a contractual discount with you. If the ERISA plan documents don't list this as a plan policy or rule (which you will NEVER SEE without the Authorized Rep appointment letter, you won't know how they treat emergency payment in the context of prudent layperson. In 2018, insurance giant Anthem announced that in six states, they would not cover “inappropriate” ED use. Other plans followed the change. In this case, they override state law patient and provider protections by contractual agreement to which you may have given advance tacit approval for them to get away with this and therefore have little standing to argue "not fair". Fair is what you negotiate. They could retrospectively deny all ED presentations that tested COVID negative on final diagnosis even though you are responsible to act under EMTALA.
• It is also not an assumed "right" by the payer to pay a non-contracted provider by reference based pricing. That's a negotiated right. On the other hand, if you signed a single case agreement (SCA) or a continuous discount agreement (CDA) with this sort of language in it, you granted that right. We might be able to argue latent ambiguity, but that's not easy to win in this case.
• It is also not a right to pay you less than your billed charges or force you not to balance bill for the billed charge amount if there is no contract. On the other hand, if you signed a single case agreement (SCA) or a continuous discount agreement (CDA) with this sort of language in it, you granted that right. We might be able to argue latent ambiguity, but that's not easy to win in this case.
• And it is also not a right for a payer to attempt to force you to "accept" a less than billed amount under duress and threat that they will pay the patient if the patient has assigned benefits to your facility and appointed your facility as the Authorized Representative. On the other hand, if you signed a single case agreement with this sort of language in it, you granted that right. We might be able to argue latent ambiguity, but that's not easy to win in this case.

If you have questions, or run into problems, put my phone on speed dial (800) 727 4160). My phone is live answered around the clock. They will patch through to me if I am available or they will take a message and I will call you back at my first opportunity.

In this instance, I am waiving all professional fees ( even for established clients) for this to help you during COVID. If you need support after we resume normal operations we can talk about a consulting agreement. These questions, though troublesome for your team are fundamental for me, and usually take less than 15 minutes to listen to what happened and guide you to resolution. I won't need to sign and accept liability for a HIPAA BAA because I don't need to see any PHI to help you.

GET THIS FORM SIGNED AT ADMISSION WITH YOUR BILLING CONSENT PAPERWORK AND ASSIGNMENT OF BENEFITS DOCUMENTS!

In the case of ERISA and Taft Hartley benefit plans of employers and unions, the ASSIGNMENT OF BENEFITS forms you usually obtain on admission is not the same. That form only allows you to accept the payment from the payor or TPA or ASO. It does not "authorize" you to appeal, question the amount paid, dispute coverage, or request and receive plan documents, utilization and payment policies and other plan documents you might need to appeal a denial. If you've been lucky enough to get them to do anything else besides accept the payment, you've been lucky. You should not assume that's going to be the case with every plan from every self funded employer, union or TPA or ASO.

Questions: (800) 727 4160 | [email protected]

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