Legal Pointers

Four Reasons why Health Plans Don't Pay Providers.

Posted by Ben Mirza | Nov 23, 2021

How Healthcare Providers Collect Receivables From Insurance Companies And Other Payers?

Why Health Plans Don't Pay - Common Reasons For Disputes Are:

  1. Medically Necessary Treatment -  A common area of dispute is whether a treatment was appropriate and necessary.  What is medically necessary is often defined in statute.  In the state of Florida there is a Patient Bill of Rights, Statute Chapter 409.9131 defines that as any good or service necessary to palliate the effect of a terminal condition or to prevent, diagnose or correct or alleviate  a deterioration that threatens life, causes pain, or results in illness.  However, contracts often resort to their ow language that may require preauthorization for coverage, prohibits retrospective payment denial on the basis of lack of medical necessity, and sets forth an expedited process for appeals. 
  2. Emergency Medical Care - the level of care is sometimes debated.  Generally what is emergency care is determined on what is called "prudent lay person standard", such that if a reasonable person determines it to be an emergency, then it is deemed an emergency.  In emergency care, it is the coding levels that often (i.e. level 4 vs level 5 claims), get disputed. This coupled with the Emergency Medical Treatment and Active Labor Act (EMTALA), providers are required to treat patients in emergency rooms for something that could very well present itself as a life threatening emergency, and in hindsight eventually may not turnout out be one.  
  3. Site of Service - Hospitals are often more comprehensive places of care than clinics, and almost always more expensive.  If a medical service that is provided in a more costly site of service, it is possible that the payer will dispute that.   
  4. Enrollee Verification - Another common set of disputes are those regarding the enrollee's eligibility, hence the manner of how the eligibility was verified matters.  If the medical service is listed in the contract it makes the verification process much cleaner, but if it is not it may be disputed.

To find out the five (5) steps you can take to collect from health insurance plans go to:

Healthcare Receivables

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