Post on 13-Jan-2016
REIMBURSEMENT DISPUTESREIMBURSEMENT DISPUTES
Charles “Scott” Nichols
Strasburger & Price, LLP
1401 McKinney St., Suite 2200
Houston, Texas 77010
713.951.5621
scott.nichols@strasburger.com
In NetworkIn Network
• Negotiated agreement between provider and payor
• Contract rate
• Did the payor pay per terms of the contract?
Out of NetworkOut of Network
• Usual and customary / UCR
• Payer tricks– Examples
The new benefit will result in a change in claims payment. Beginning October 1, 2010, the new benefit will be based on a percentage of the Medicare rate for the service, rather than the current benefit based on “reasonable” or “prevailing” charges.
The new benefit will result in a change in claims payment. Beginning October 1, 2010, the new benefit will be based on a percentage of the Medicare rate for the service, rather than the current benefit based on “reasonable” or “prevailing” charges.
If the member or subscriber receives services from a non-contracted licensed Ambulatory Surgery Center provider, BCBSTX will pay the member directly, except as otherwise required by law.
If the member or subscriber receives services from a non-contracted licensed Ambulatory Surgery Center provider, BCBSTX will pay the member directly, except as otherwise required by law.
RecoupmentRecoupment
• SIU – fraud, embezzlement (the Payor’s SIU or the provider’s SIU?)
• One of the evolution of excuses for non-payment– Medicare– Private Payor
ERISAERISA
• Any group health plan
• Fully insured or employer funded
ASSIGNMENT AND DESIGNATION OF AUTHORIZED REPRESENTATIVE
ASSIGNMENT AND DESIGNATION OF AUTHORIZED REPRESENTATIVE
• Assignment of benefits alone is not enough – the assignment must specifically designate provider as authorized representative and assign provider rights to pursue reimbursement, pursue appeals, engage in litigation and pursue breach of fiduciary duty causes of action.
• Your assignments likely are insufficient!
VALID ASSIGNMENTVALID ASSIGNMENT• THEN – you have the right to demand:
• copies of the plan
• copies of the summary plan description
• identification of the plan administrator, and
• all documents and information considered in making claim determinations, including fee schedules
DISCLOSURE OF FINANCIAL INTEREST
DISCLOSURE OF FINANCIAL INTEREST
• Physician
• ASC
YOU CANNOT WAIVE CO-PAY AND/OR CO-INSURANCE
YOU CANNOT WAIVE CO-PAY AND/OR CO-INSURANCE
Financial policy onboard
FALSE CLAIMS ACTFALSE CLAIMS ACT
Government funded Payor – extra consideration to what you do
THANK YOUTHANK YOU