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