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Episode 8: ROC Monthly Mastermind Call
Health Insurance Reimbursement Litigation for Your Rehab Center
We spoke with Matt Lavin, partner at Arnall Golden Gregory LLP, about recent developments in treatment center reimbursement litigation and litigation as a business tool to increase payer reimbursements.
Matt is based in DC but represents clients all around the USA. His speciality is in healthcare reimbursement litigation and disputes, and he focuses on disputes against commercial health insurance companies, specifically those involving low pays or no pays.
Members of the ROC group shared their concerns about insurance companies, such as getting payments on time, “playing the game” with them, overcoming the local monopolies, navigating audits, poor communication, non-payments, low payments, and the resulting inability to scale their business when faced with these challenges.
Matt shared information about best practices, recent developments in health insurance lawsuits, and key considerations to help with claims.
All information shared in this ROC meeting is meant to be informative and doesn’t not constitute personalized legal advice.
Matt explained that the number one issue with the health care providers he works with is not getting paid. The health insurance system is flawed, and insurance companies function as private entities seeking profit, even when they claim the opposite. These publicly traded companies exist with one goal in mind: to make as much money as possible for shareholders. Simply put, withholding healthcare payments maximizes profits for shareholders.
Remember, big insurance companies do not take your claims personally, so you should not take them personally either- But you should do something about it if you do not receive payment to which you are entitled.
Recent developments in health insurance lawsuits
Many insurance companies claim their agreements are guidelines, but they actually are formal agreements based on certain conditions being met. The standard language that you may see on agreements, such as disclaimers along the lines of “this is not a guarantee of receiving pay” are used by insurance companies to imply they are not obligated to pay. What those agreements mean in actuality is that the insurance company is required to pay, as long as certain conditions are met:
1. Getting authorization
2. Providing services
3. Timely billing
If you do all these things, you are entitled to pursue against the insurance company if they don’t pay you.
When pursuing claims or suing a company, it is only necessary to go after the entity you are submitting the claims to, even if you have clients from around the country. You don’t have to worry about all the branches or the umbrella corporation, you just need to file the case against your local entity or the one with which you are dealing.
Different types of denials
There are two basic types of denials that insurance companies will issue:
Administrative denials - this includes aspects like improper billing, improper authorizations, or human error, like not checking off the right box. These are the most common type of denials.
Coverage denials - this includes reasonings like the person not needing medical assessment or the client not having benefits for the claim.
Things to remember
Ensure you have good records of what happened, charts signed and dated, and records of all services.
California has very short statutes of limitations for litigation claims; it is 2 years on breach of contract. In other places, it might be 6-10 years. If you’re in California, you want to be careful with the timeliness of your claims, or there may not be anything you can do.
Know your rights. You are in a business relationship with these insurance companies. They are not doing you a favour by paying you the money; it is part of the agreement.
Be aware that there are opioid manufacturers that are filing for bankruptcy. You may be able to file a claim within that bankruptcy for unpaid services that you rendered to opioid use disorder clients.
“Rule of thumb for all details and underpayments is to appeal, appeal, appeal.”
Document all appeals. Be ready to send in all records, follow up with a phone call, and take notes on it.
If you use third party billing, download and keep copies of all your records. A lawyer needs access to your documentation to be able to help you.
Key considerations and reimbursement remedies
Provider agreement controls
Defined terms and rates
Demand letters pursuant to terms of provider agreement
Litigation for breach of contract (provider agreement)
Each admit is a new contract to be formed with provider
Patient plans and plan terms (e.g. anti-assignment; UCR, etc.)
Record keeping and follow-up are essential
Demand letters based on promise to pay
Litigation based on promise to pay (first party standing)
Litigation based on AOBs and ERISA duties (derivative standing)
Best practices: What you can do to increase your odds of getting paid on claims
Prepayment review often a way to avoid paying reimbursements for medially necessary treatment without officially ‘denying’ claim
Essential to respond to all requests in a prompt and timely manner
Know the terms of your contract as to the obligations of each party
Respond in a timely manner and be familiar with the terms of your contract
Review your contract and know when, if ever, you are required to submit to arbitration of disputes
Verification of benefits calls
Take detailed notes and ask detailed questions
Maintain these records and know where they are kept
Assignment of benefits
Detailed and thorough
Power of attorney
Know state requirements and have a notary on staff
Timely billing, follow-up, and appeals
Know your deadlines
Keep detailed records (even if you use a third party biller, copy and same all EMR)
ERISA plans may have short time frames to respond
Always have at least two appeals, preferably written
It is important to have clients sign a waiver that they are responsible for all amounts not covered by insurance, but it is a best practice to do balance billing. To document that you are holding patients responsible helps you when you interact with the insurance companies. If you are to sue, it shows that those patients have been damaged.
Interested in an AOB?
If you are interested in receiving the AOB, please reach out either:
Mark Shandow- email@example.com
Matt Lavin- firstname.lastname@example.org
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