Tag Archives: Claims Denial

HMO Patient Emergency Care Reimbursement

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By: Bradley M. Seldin, C0-counsel Guest Contributor

Prohibitions against balance billing Health Maintenance Organization (HMO) patients have been around for more than a decade, but many non-contracted providers to HMO patients still don’t fully understand their rights to payment when it comes to collecting monies from patients and HMO’s.

HMO’s often have predetermined rates they pay to non-contracted healthcare providers; sometimes they are artificially low, do not reflect what is written in the member’s contract, or do not abide by what is required by applicable law.  As a result, these providers may end up being underpaid if they don’t have a written contract with the payor and they do not understand the payment methodology being applied to them.  This is of particular significance to emergency care providers. ER doctors and hospitals must, by law, provide emergency care without regard to whether the patient has an ability to pay for the treatment received.

Following their provision of emergency care, medical providers often question the payment obligations under the patient’s Health Maintenance Organization contract. If the emergency medical provider has a direct written contract, the reimbursement is governed by that participating provider contract’s reimbursement terms.   Continue reading →

How to Make an Out of Network Appeal Count

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out of network appealBy: Karina Gonzalez

As many know, out-of-network providers have much different appeal rights with commercial plans than in-network providers.  It is important to understand each health plan’s appeal procedure as well as time requirements for an appeal may vary.  However, the appeal process is still one of the most important tools providers have to get paid in the current environment of reduced reimbursements, caps on the number and frequency of services, bundled payments based on specific codes, delayed payments, daily errors in claims processing leading to denied claims, claw backs, and the list goes on.   Continue reading →

Managed Care Contracts: Watch Out for Definitions Section Pitfalls

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Contract CWBy: Karina Gonzalez

One of the most commonly overlooked components of a managed care contract is the definitions section despite the fact that what is contained here will affect the contracted provider on a daily basis.  Contract terms that are too generic so that they are not clearly defined and understood as they relate to a particular area of practice can have a direct influence on clinical decision making.  A patient may need a higher level of care but be approved for a lower level only.  The provider knows that a patient may suffer if the level approved will not treat the illness or that the patient’s condition could deteriorate without a higher level of care.

Let’s take, for example, the definition of medical necessity in a contract. Who decides medical necessity?  Is it the provider or is it the managed care organization (MCO)?  Many contracts state that the term “medical necessity” relates only to the issue of reimbursement.  Further, that the approval or denial of a claim is “for reimbursement purposes only” and should not affect the provider’s judgment on whether treatment is appropriate to treat the illness, symptoms or complaints of the patient.   Continue reading →

Audit Decisions Leading to Absurd Outcomes

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healthcare businessBy: Karina Gonzalez

Commercial plans continue their audit activity in 2016 demanding many changes and adjustments yet giving little in return. The 2015 audits have not been completed for the majority of substance abuse providers in South Florida, yet the commercial plans have arbitrarily stopped paying new claims even though it takes them at least 6 months to complete a post payment audit.  If and when a provider finally gets an audit result, payors are imposing requirements that just are impossible to meet.

Payors do not appear to be paying attention to the public health crisis of substance abuse addiction and the ever growing need for treatment.   The assumption is being made by the payors that all providers in this space are over utilizing services and engaged in fraudulent practices, despite the reality that  many providers are doing just the contrary.    Continue reading →

Act or React? Rehab Industry Transformation

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florida healthcare lawyerBy: Jeff Cohen

By now, it’s not news in Florida that drug and alcohol recovery providers are staring devastation in the face as payers continue to mount non-payment offensives.  As payers one by one march on the industry and starve providers of cash flow for operations, many providers can be expected to shut down.  To make matters worse, as the popular media continues to act as a conduit for gross misrepresentations of industry providers, the public’s affection for the industry can’t be expected to improve.  This makes the future look especially bleak for the industry, and yet the silence and stillness of providers is baffling.

Given the breadth of the payer problem (many simply aren’t paying providers), why are we not seeing a slew of lawsuits filed by providers?  In nearly 30 years as a Florida healthcare lawyer, I’ve never seen a healthcare sector so hammered by insurance companies.  And I’ve never seen it unanswered in court. Continue reading →

Addiction Treatment is a Story in Search of a Villain

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healthcare business

Hastiness and superficiality are the psychic diseases of the twentieth century, and more than anywhere else this disease is reflected in the press— Alexander Solzhenitsyn

By: Jeff Cohen

I read an article in a local paper the other day.  It was about (a) a guy who owned a treatment center (who has not been charged with committing a crime), (b) a lawsuit filed by a large insurance company against a toxicology lab that the insurer owes millions, and (c) the fact that insurance companies pay a lot for toxicology lab testing.  I scratched my head, wondering how there was anything newsworthy there.  The “story” being sold by the paper, however, created a story with a villain (the providers of services to people in recovery from drug and alcohol addiction) and a “victim” (people receiving care for addiction).  I can’t resist responding.

There’s a difference between something that’s interesting and worthy of comment vs. a journalistic attempt to concoct controversy and intrigue that people might buy.  There’s not much of the former, but a lot of the latter.  People in recovery being victimized by horrible, greedy people is an interesting story.  Unfortunately, it’s off the mark and really not helpful to anyone.

There are three pretty safe assumptions we can almost all agree on:  first, there are a lot of people who want to live life without active addiction.  Second, many of them think they need help to create a better life.  Third, some providers of help to people in recovery make a bunch of money providing that service. Continue reading →

Managing Managed Care

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managed care moneyBy: Valerie Shahriari

While your healthcare business may be compliant with billing regulations and coding, this does not mean that your payer is compliant and has paid you correctly per your contract.  Providers know that Fraud and Abuse has been one of the largest areas of focus for payers and the government over the past 20 years.  Due to this attention, many healthcare businesses engage auditors to audit their compliance of claims quarterly or annually.  However, in addition to compliance audits, a provider should be auditing their payer interaction to create a dynamic blueprint of denial management and payment recovery.   The AMA states that a 5% denial rate for an average family practice equates to about $30,000 walking of the door.  A good benchmark for payer compliance would be a denial rate of 5-10%.  Often times, practices and healthcare businesses operate with a much higher rate, and even in the 20-30% range without even knowing it.

When auditing the payer interaction, several components should be included in the review including:

  • Denial rate percentage
  • Aging of claims paid for 30 day, 60 day, 90 day, over 120 day period as an Aggregate
  • Aging of claims paid for 30 day, 60 day, 90 day, over 120 day period by each Payer
  • Claims denied categorized by denial reason as an Aggregate for previous 12 months
  • Claims denied categorized by denial reason by each Payer for previous 12 months
  • Claims that have been appealed, the date submitted, the date of the outcome, the outcome by each Payer
  • Claims not paid according to fee schedule as an Aggregate for previous 12 months
  • Claims not paid according to fee schedule by each Payer for previous 12 months

Continue reading →