You Know Subro (Subro and Reimbursement)
HIPPA and Rawlings Way
Grab bag
Recovery Discovery (Sources of Recovery) & Rights
Miscellaneous
"Calling Dr. Trine" (Reduction Doctrines)
100
Define Subrogation
Substitution of one party in the place of another with respect to a legal claim.
"Standing in the shoes" of our member with regards to rights of recovery resulting from an injury or accident.
100
What does PHI Stand for?
Protected Health Information
100
What was the top selling album of 2024?
100
What are the sources of recovery available for a Motor Vehicle Accident?
(hint: there are AT LEAST 4)
1- PiP
2- Medpay
3- UM/UIM
4- Bodily Injury
POTENTIALLY (rare): Dram Shop, Product Liability, Umbrella
100
What do we call subrogation where a state law requires the health plan language to contain a subrogation provision?
Contractual Subrogation
100
What is the Common Fund Doctrine?
The Common Fund Doctrine is a state mandated statute that requires lien holders to reduce their lien to accommodate for Attorney's fees and costs.
200
Define Reimbursement
The right of an insurer to make a claim against its own insured after the insured has recovered funds from the at-fault party that includes the expenses paid by the insurer.
"Right of recovery" for paid medical when an insured member has received a settlement from an accident or injury.
200
Give me 3 examples of a HIPPA violation that could occur in the course of your job as an analyst.
1- Letter sent to incorrect fax/mailing address
2- Disclosing PHI via phone/email to an unverified party.
3- Sending claims information to a party that we don't have the right to pursue.
4- Sending PHI out via unencrypted email.
200
What movie released in 2025 had viewers throwing popcorn, drinks, and even live chickens during one particular scene?
200
What are the sources of recovery for a slip and fall (premises claim) at a commercial property?
1- Premises Medpay
2- Premises Bodily Injury Liability
200
What do we call subrogation based on fairness?
Equitable Subrogation
200
What is the Made Whole Doctrine?
A state statute that prevents lienholders from collecting from a settlement if the injured party has not been fully compensated for their loss.
300
A member who lives in Kentucky gets in a Motor Vehicle Accident (MVA) while on vacation in California.
1. Which state's SUBROGATION laws will we follow?
2. Which state's REIMBURSEMNT laws will we follow?
1. California
2. Kentucky
"We SUBRGATE where the accident happens, we REIMBURSE where the member lives."
300
Who do we report HIPPA violations to?
(name and job title)
Pat Tobin, Privacy Officer
300
Who won the 2025 NCAA Men's College Basketball Championship?
300
David (Driver) and Pam (Passenger) were rear ended by Ian a drunk driver. The Police Report also indicated David was driving 25mph over the speed limit.
What POTENTIAL SoR are available for Pam?
1- PiP (1p)
2- Medpay (1p)
3- BI (Ian) (3p)
4- BI (David) (3p)
5- UM/UIM (1p)
6- MAYBE Dram shop? (3p)
300
Which parties can we send PHI to for a file we are working?
A. The member's attorney
B. The at-fault driver
C. The Member
D. Any SoR we have recovery rights to
E. A shady person on Facebook who pays you $8 for each SSN you send to them.
A, C, D
"If we can sue them, we can send them PHI."
300
What is the "Kenny Rogers Rule" when we talk about the Made Whole Doctrine?
If the injured party (or their attorney) do not collect ALL available coverage, then they cannot argue the patient WAS NOT made whole.
400
1- Who is a Subrogation claim against?
2- Who is a Reimbursement claim against?
1- An "At-Fault" or otherwise responsible party.
2- The insured (our member)
400
What are the 4 phases of THE RAWLINGS WAY (in order)?
1. Identify
2. Notify
3. Subrogate
4. Negotiate
400
Who won the 2025 Super Bowl?
400
David (Driver) and Pam (Passenger) were rear ended by Ian a drunk driver. The Police Report also indicated David was driving 25mph over the speed limit.
What POTENTIAL SoR are available for David?
1- Pip (1p)
2- Medpay (1p)
3- BI (Ian) (3p)
4- UM/UIM (1p)
5- MAYBE Dram Shop (3p)
400
1. What do the YELLOW states on the map allow?
2. What do the GREEN states on this map allow?
3. What do the RED states on this map allow?
1. Reimbursement ONLY
2. Subrogation & Reimbursement
3. No Subrogation & Reimbursement
400
Our member's Attorney has settled a case for $100,000. We have a lien for member's health plan totaling $10,000.
The Attorney had a 40% fee. Assuming we are in a state that requires a Common Fund reduction AND the health plan IS NOT Preemptive, How much can we seek to collect for our client?
$6,000
We reduced our lien by 40% ($4,000) to accommodate for the PLA fees.
500
What are 3 benefits to pursuing SUBROGATION over REIMBURSEMENT?
1- Subrogation is faster paying
2- Subrogation causes less member abrasion
3- More likely to collect our full lien from subrogation that reimbursement.
4- Subrogation DOES NOT require the member to pursue a recovery, Reimbursement does.
5- Subrogation litigation takes longer than reimbursement.
6- Subrogation litigation is more expensive
500
Per The Rawlings Way, once a file is opened we have ___ days to COMPLETE the identify and Notify phases.
30 days
(7 days to BEGIN the identify phase, and 30 days to complete it and Notify all involved parties)
500
How many Jelly Beans fit in a standard quart sized (32 oz) mason jar? (Closest without going over)
360
500
David (Driver) and Pam (Passenger) were rear ended by Ian a drunk driver. The Police Report also indicated David was driving 25mph over the speed limit.
How much coverage is AVAILALE for Pam?
How much coverage is AVAILABLE for David?
David Dec Page:
PiP: $10,000
MP: $500
BI: $25k/50k
UM/UIM: $150k/$250k
Ian Dec Page:
PiP: $10,000
MP: $0
BI: $15k/30k
UM/UIM: $0
Pam- $200,500
$10k PiP, $500 medpay, $25k BI(1), $15k BI (2), $150k UM/UIM
David: $175,500
$10k PiP, $500 medpay, $15k BI (2), $150k UM/UIM
500
Our member lives in New Mexico (NM) and gets in an accident in Colorado (CO). What recovery rights does the FULLY INSURED (non-preemptive) plan have for this accident?
Reimbursement in New Mexico (NM) since we do not have Subrogation rights in Colorado (CO)
500
Our member's Attorney has settled a Motor Vehicle Accident (MVA) case.
The case settle for $87,000 from the at-fault Bodily Injury Policy. There was no PiP, Medpay, or UM/UIM.
We had previously spoken with the At-Fault insurance who told us the policy limits were $100,000.
The attorney is asking us to waive our lien as their client was not made whole due to significant lost wages and pain and suffering.
What would our response to this argument be?
"It looks like you did not get the full Bodily Injury Policy Limits, since there was money left "on the table" so to speak we cannot accept a Made Whole argument."
BONUS- We cannot waive our lien, but we can see about a Common Fund reduction depending on the state and our Plan's rights.