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Home | About HRI | Investor Relations | Future Pages | Talk to HRI Seek First To Understand At HRI, recoveries are made every day based on the facts of an accident. But, when an HRI examiner is faced with a case which demands a high level of technical expertise as well as their ability to understand the emotional aspects of a case, a real difference is evident in the recovery. In difficult negotiations, HRI examiners must remain sensitive to the clients' injured members while, at the same time, protecting the recovery interests of the health care payor. The resolution of a recent case epitomizes HRI's willingness to work with the member -- and it established a benchmark to measure HRI's commitment to serving its clients fully. HRI identified an accident file involving a teenage girl who was injured while riding as a passenger in her boyfriend's car. Following a complete investigation, HRI's examiner presented a consolidated statement of benefits to the liability carrier. When there was no timely response, the examiner personally contacted the liability carrier to request reimbursement. In the course of the negotiations, the examiner discovered the member's family had not filed a claim on the accident. The attorney for the carrier explained that the member's religious beliefs prevented her from filing a personal injury claim against the boyfriend's policy. Seeking to further understand the situation, the examiner asked the member to consider filing a claim for reimbursement of medical bills only -- one which would not pursue pain and suffering. This approach would transfer the expense from the healthcare payor to the correct insurer, the liability carrier. When presented with this option, the member's family agreed the health plan was entitled to reimbursement for the medical bills and a claim was initiated. At this point, it would be logical to assume that the case was resolved. However, the examiner's experience indicated that continued monitoring of this case was needed. In periodic follow-up with the liability carrier, the examiner learned the member required future medical care relating to injuries received in the accident. Unfortunately, the member's insurance was in jeopardy due to a pending loss of employment. Another solution was needed to provide the necessary medical care and to protect the health plan from future medical expenses. The examiner recommended development of a settlement agreement to cover the member's anticipated medical care. Attorneys for HRI's law firm, Sharps and Associates, the examiner and the client developed a settlement which provided the member with $35,000 for future medical expenses and protected HRI's client from the first $35,000 in future bills, should the injured party still be insured at the time of her surgery. The settlement was accepted by all parties. HRI subsequently recovered more than $154,000 from the boyfriend's remaining liability and medical benefits' policies. The HRI examiner's dedicated efforts to understand the member's situation, combined with their sensitivity to the member's relationship with the liable party, proved to be beneficial for all the parties involved. The HRI emphasis on fully understanding each and every situation became the determining factor in the positive resolution of this Case of the Quarter.
HRI/Client Partnerships: Beating the Odds Outsourcing is often the best option in today's fast and cost conscious world of business. Experienced managers have learned that outsourcing is most successful when they maintain a sense of commitment to the outcome. They know the best results are obtained when they provide their vendors thoughtful and timely input. This Case of the Quarter demonstrates the importance of HRI's client partnerships. HRI routinely searches for more than 3,500 ICD-9 codes to identify accidents among its clients' paid claims. Potential accidents may be rejected for many legitimate reasons -- but occasionally personal circumstances prevent an accident from qualifying for recovery. In these cases, HRI's client contacts can provide valuable information. This was the situation in a recent case. HRI's client contact was aware of a member who was a known hemophiliac, and who had been involved in an accident on the job. While processing the claims resulting from this member's accident, the client discovered that the file was not reported on HRI's monthly reports. He called the HRI recovery examiner to investigate the situation. The examiner determined that HRI had not received the claims data from the client due to the treatment being attributed to the member's hemophilia, rather than an accident. The client's early notice of its payment to the provider gave HRI an edge in pursuing this recovery. And, the examiner fully applied HRI's philosophy of planned persistence in working through the file. Her investigation uncovered the fact that the hospital had originally billed the state's Workers Compensation Bureau but had been denied payment due to an error in the ICD-9 code. She successfully encouraged the hospital to correct the error and resubmit the claims to the Bureau. The examiner then focused her efforts on obtaining payment from the Bureau. After repeated calls, the case appeared headed to conclusion -- but the Bureau made only a token payment! The examiner went back to the drawing board to develop a strategic action plan. Her persistence in directly contacting the hospital administrator resulted in the hospital making a special payment request to the Bureau. Four months and countless phone calls later, HRI recovered full payment of $181,000 for its client on the member's accident claims! HRI's examiner summed it up, "The client's personal knowledge of the member's health circumstances helped set this recovery in motion; and HRI's philosophy of persistence really paid off. This is a great example of how important the HRI/client partnership is to beating the odds!" Home | About HRI | Investor Relations | Future Pages | Talk to HRI | ||