reimbursement disputes charles “scott” nichols strasburger & price, llp 1401 mckinney st.,...
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REIMBURSEMENT DISPUTESREIMBURSEMENT DISPUTES
Charles “Scott” Nichols
Strasburger & Price, LLP
1401 McKinney St., Suite 2200
Houston, Texas 77010
713.951.5621
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In NetworkIn Network
• Negotiated agreement between provider and payor
• Contract rate
• Did the payor pay per terms of the contract?
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Out of NetworkOut of Network
• Usual and customary / UCR
• Payer tricks– Examples
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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.
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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.
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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
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ERISAERISA
• Any group health plan
• Fully insured or employer funded
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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!
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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
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DISCLOSURE OF FINANCIAL INTEREST
DISCLOSURE OF FINANCIAL INTEREST
• Physician
• ASC
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YOU CANNOT WAIVE CO-PAY AND/OR CO-INSURANCE
YOU CANNOT WAIVE CO-PAY AND/OR CO-INSURANCE
Financial policy onboard
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FALSE CLAIMS ACTFALSE CLAIMS ACT
Government funded Payor – extra consideration to what you do
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THANK YOUTHANK YOU