reimbursement disputes

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REIMBURSEMENT DISPUTES. Charles Scott Nichols Strasburger & Price, LLP 1401 McKinney St., Suite 2200 Houston, Texas 77010 713.951.5621 scott.nichols@strasburger.com. In Network. Negotiated agreement between provider and payor Contract rate Did the payor pay per terms of the contract?. - PowerPoint PPT Presentation

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  • REIMBURSEMENT DISPUTES

    Charles Scott NicholsStrasburger & Price, LLP1401 McKinney St., Suite 2200Houston, Texas 77010713.951.5621scott.nichols@strasburger.com

  • In Network

    Negotiated agreement between provider and payor

    Contract rate

    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

    PhysicianASC

  • YOU CANNOT WAIVE CO-PAY AND/OR CO-INSURANCE

    Financial policy onboard

  • FALSE CLAIMS ACT

    Government funded Payor extra consideration to what you do

  • THANK YOU