Providers Getting Paid from Hard to Collect Health Plans?

When a health plan fails to pay, then disputing it is time consuming and confusing.   They often do not give the clear reasons for denial, and even if those reasons are cleared up, they will often simply deny payment.  Before you start the fight, if you have not yet followed the ideas and the procedures outlined in "How Providers Collect from Payors" you may want to do that first.  Below is the next level up, it is the escalating of the matter to the next level and demanding what your practice is owed.

How to Collect Money from Health Plans?

  1. Read your health plan contract for alternatives available
  2. Alternative Dispute Resolution (ADR)
  3. What happens when a Provider and a Payer do not have a contract
  4. Last but not least, you go to court what you are owed.
Contingency Legal Fees

There are often either contractual and/or statutory provisions that allow you to claim legal fees and costs against a health plan.  Call us, we will look into it for free for you. 

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. 

Failure to provide a Clean Claim is one of the most common defenses payers use. A standardized claim form like the CMS 1500 or the CMS 1450 (UB-04) are part of the Medicare program and they generally are broad enough that if they are complied with, it typically means that the claim was likely be a clean claim. Florida Statute 641.3155 also defines rules for prompt payment for Clean Claims. 

If you or your business are struggling with how far to push the issues with a health plan payer, it would help if you had a second opinion to figure out what your options are.  At Mirza Healthcare Law Partners, we can help you figure out what what your options are.  Our initial case consults are free, and if we take on your case to go after the insurance company we do it on a contingency, so you don't pay any fees unless we collect. 

Call Ben Assad Mirza Cell/Text 954-445-5503, [email protected]

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If you are a physician, nurse, dentist, pharmacist, hospital, physician group, or medical lab looking for legal advice then you’ve reached the right site. Today’s healthcare environment is riddled with complex issues of professionalism, market strategy, and the law. Contact us now!

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