ERISA applies to more than 80% of non Medicare and non Medicaid claims - in spite of the fact most offices have no idea they are filing claims pursuant to federal ERISA law. Every single medical office or hospital person reading this knows they get DEMANDS from insurance carriers giving them a limited time to refund on previously paid claims or the carrier will recoup from another claim. Yes - this causes headaches in the bookeeping - but more importantly - it's giving money that belongs to the practice or hospital to the insurance carrier WHO IS NOT LEGALLY ENTITLED TO THAT MONEY.
Think about this. If the carrier sent the check to the patient and the patient deposited that check in the bank, whose money is it? What if that same patient then comes to your office and hands you a check or cash? Would you think it's right or allowed for the carrier to come ask YOU for the money they paid the PATIENT? IT IS NO DIFFERENT and the US Supreme Court have ruled on this in favor of the physicians and hospitals every time! So - why are YOU letting the carrier recoup? Don't be stupid and let them. This book will show you how to stop them with a very simple fax to the carrier.
This book gives detailed step by step instructions, with sample letters to use to force insurance carriers to follow the law. Before a practice can do this, they must first LEARN the law and understand that the insurance claims they are filing are NOT their own claims. The claims are not the claim of the MEDICAL OFFICE, but instead - are the PATIENT'S claims. Until an office, a biller, a coder or a manager learns this basic fact, they are not doing their employer the service that is due to their employer.
This book explains it in details and tells them how to:
Make carriers honor the 1 to 2 year filing period found in policies
Stop a carrier from Recouping on claims
Make carriers pay on services they may deem investigational
Make carriers follow current bundling rules instead of their own
Stop carriers from downcoding claims properly billed
Make carriers honor the 180 day appeal periods
I have used Don’s books, Coding Advisor, slide rule and I am love them all. They are done so expertly yet are so easy to use. Don is a great resource to anyone in the coding field.
Lois A Simmons, RHIT, CCS-P
Coder/Abstractor, OSF Medical Group
Peoria, IL | 61614
"I have a family with BCBS insurance. The 2 children came in on the same day for the same reason. One paid with no problem. The other one has been denying for 8 months now saying they paid the patient. The mother has been calling them and they were telling her they were going to pay it, but they were still sending me denials stating they paid the patient. I got fed up with it and sent an ERISA letter to the BCBS CEO and a copy to the patient on 07/28/15. I received payment today. :) Don's ERISA letters really do work. This one claim paid more than what the book cost me, so I would say that's a pretty good bargain." _
Tri-Care Family Medicine _
"Don, your advice was right on the money! I received a request for a refund due to policy termination and responded on 06/30/15 with your letter from your book addressed to the CEO. I was delighted to receive a call on 07/07/15 indicating the request had been made in error and to disregard it. How refreshing to have something work the first time and immediately. Please feel free to share this on your list serve to encourage them to get on the ERISA band wagon.
St. Cloud Ear, Nose & Throat Clinic
"Can't stress enough to you all how effective it is when you send your complaints directly to the CEO/Attorney's of the Insurance Companies. I have no doubt that my picture is on many Dart Boards at this point. I had sent an appeal to Anthem 3 times without a response and then tried to contact our Provider Rep by email, fax and by phone and couldn't get a response from her either. I typed up a letter to the CEO explaining how this lack of response was "In my opinion' a violation of the Fair Claims Act and said if I recvd no response within 5 days we would look into a potential law suit with punitive damages. Low and behold I got a call from our Rep THE NEXT DAY! The apologies were abundant so I could tell she must have had the hammer dropped on her. I've also had the UHC rep practically beg me to come to her first to which I replied, "I'm sorry but when I feel illegal activity has been done ( the discussion was regarding take-backs in bulk checks) I feel the need to let the CEO be accountable". Let's just say I don't think I'll be invited out to dinner any time soon :-)"
Womens Care Center of Cols, Inc.
"How appropriate to end the day with notification from a major insurance company that an appeal previously denied for timely (due to the 90 day payer contract) was successful! I solicited some help and followed the procedures outlined in Don's ERISA book and it worked. Prior attempts the "conventional" ways had failed and without the ERISA knowledge the claim would have been written off. "
WHY LET THE CARRIERS RECOUP FROM YOU WHEN THE LAW SAYS THEY CAN'T? THE ONLY GET AWAY WITH IT BECAUSE OF IGNORANCE OF WHAT THE LAW SAYS. GET THE BOOK TODAY AND STOP THEM.
PQRS #2: Diabetes Mellitus: (LDL-C) Control
PQRS #3 BP & Diabetes
PQRS # 51 – (COPD): Spirometry Evaluation
PQRS #126 – Diabetes And Foot Exams
New & Established Patients
Medicare Advanced Beneficiary Notice (ABN)
Using A Nurse Practitioner Or Physician Assistant
Incident-To Is Not For Physicians
Billing Family Members
Members of Patient's Household
Charges for Physician and Physician-Related Services
Charges for Items Furnished by Non-Physician Suppliers
Medicare Secondary In Hospital
Pre-Op Physicals Are Consultations
Office & Other Outpatient Visit Codes
When Doctor Doesn’t Document Enough
Linking Diagnosis Code To CPT Code
Local Coverage Determinations (LCDs)
Choosing The ICD-9 Code
When Is A Nurse Visit (99211) Appropriate?
99211 & PT/INR
99211 for Anticoagulation Management “Do’s”
99211 for Anticoagulation Management “Don’ts”
Using Time To Determine Level Of Code
Prolonged Service Coding (99354 – 99357)
Initial Inpatient Care (Admits)
Admit From Emergency Room To Inpatient Hospital
Admit To Critical Care From E.R.
Critical Care In Any Place Of Service
Outpatient (24 - 48 Hour) Observation Admits/Visits
Patient Is In Observation For Less Than 8 Hours:
Patient In Observation More than 8 Hours, But Discharged Same Date
Patient In Observation Over More Than One Date
Discharging The Patient From The Hospital
Hospital Discharge & Nursing Home Admit On Same Day
Pronouncing Death – Signing Certificate
Modifier 52 Vs Modifier 53
Progress Note Blunders
Signed, But Not Read
Sports & School Physicals
Health Reform and more
The REVISED Unfiltered Guide
to Medical Office Management
I think managers and physicians would be hard-pressed to find this amount of information available in one book. The Unfiltered Guide to Medical Office Management is the "bible" of medical office management! What you have successfully developed is a comprehensive guide to just about all aspects of physician billing, coding, collections and compliance in one easy to read (and entertaining) tome! Just implement a few of these tips and you are on your way to a more efficient practice. Don has provided information on increasing revenue and sharpening efficiency...both extremely important in these tough times. ~ Charlene Endre-Burgett, MS, CMA (AAMA), CPM, CPC, CMSCS, - Administrator, North Scottsdale Family Medicine
Don has written four books . The newest one (The Unfiltered Guide to ERISA for Medical Practices) is our hottest seller as it helps you to force carriers to pay on claims they should pay on - when they don't want to) You can order it now at https://shop.donself.com
TOTAL Website Visits!
THE UNFILTERED GUIDE TO ERISA FOR MEDICAL PROVIDERS
This book simplifies the 1974 law that IS the BEST FRIEND to any smart medical biller, coder or physician that sees commercial insurance patients.
The saddest thing about this subject is that more than 95% of people working in medical offices, hospitals, billing agencies and even attorneys dealing with medical offices know almost NOTHING about ERISA - yet - ERISA can be THE BEST FRIEND to any medical office or hospital - once they know how it can help them.
Marketing your practice
Column In Local Newspaper:
Local Speaking Engagements:
Medicare Participation Status
Participation With Managed/Mangled Care Plans
Red Flag Laws
Provider Identity Theft
Copying Patient’s Driver License
Copying Military Id Cards Is Legal
Patient Hesitant To Share Social Security Number
Copying Medicare Cards
Prior To The Patient Arriving
When The Patient Arrives
The Reception Area
Why Patients Leave Clinics
Collecting The Deductible And/Or Co-Insurance
Fees & Discounts
Double Booking – Double Trouble
Divorce Poem To Patient
47 Million Uninsured?
Collecting The Co-Pay Prior To Seeing The Doctor
Office And Insurance Theft/Fraud
The Medical Office Manager
HIPAA – Not HIPPA
Breach of PHI
Patient Sign In Forms
Locking File Cabinets
Calling Patients By Name
E&M DOCUMENTATION PRINCIPLES
Medicare Documentation Pointers
E&M Chief Complaint:
History Of Present Illness
Review Of Systems (ROS)
ROS – Non Contributory
Past, Family, Social History (PFSH)
Exam Body Areas
EMR Incentive Payments
EMR – True Benefit
PQRS IN 2015
PQRS # 1 – Diabetes: Hemoglobin A1c
This book does not take the normal approach to medical office management (not making waves, using politically correct language) as it gives practical information on how to increase income, improve patient care, improve employee morale, and how to stay out of trouble with Medicare, Medicaid and commercial carriers.