Post on 30-Dec-2015
Embed Size (px)
DESCRIPTIONREIMBURSEMENT DISPUTES. Charles Scott Nichols Strasburger & Price, LLP 1401 McKinney St., Suite 2200 Houston, Texas 77010 713.951.5621 email@example.com. In Network. Negotiated agreement between provider and payor Contract rate Did the payor pay per terms of the contract?. - PowerPoint PPT Presentation
Charles Scott NicholsStrasburger & Price, LLP1401 McKinney St., Suite 2200Houston, Texas firstname.lastname@example.org
Negotiated agreement between provider and payor
Did the payor pay per terms of the contract?
Out of NetworkUsual and customary / UCRPayer tricksExamples
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.
RecoupmentSIU fraud, embezzlement (the Payors SIU or the providers SIU?)One of the evolution of excuses for non-paymentMedicarePrivate Payor
ERISAAny group health planFully insured or employer funded
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 ASSIGNMENTTHEN you have the right to demand:copies of the plancopies of the summary plan descriptionidentification of the plan administrator, and all documents and information considered in making claim determinations, including fee schedules
DISCLOSURE OF FINANCIAL INTEREST
YOU CANNOT WAIVE CO-PAY AND/OR CO-INSURANCE
Financial policy onboard
FALSE CLAIMS ACT
Government funded Payor extra consideration to what you do