REIMBURSEMENT DISPUTES Charles “Scott” Nichols Strasburger & Price, LLP 1401 McKinney St., Suite 2200 Houston, Texas

In Network Negotiated agreement between provider and payor Contract rate Did the payor pay per terms of the contract?

Out of Network Usual and customary / UCR Payer tricks –Examples

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.

Recoupment SIU – fraud, embezzlement (the Payor’s SIU or the provider’s SIU?) One of the evolution of excuses for non- payment –Medicare –Private Payor

ERISA Any group health plan Fully 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 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

DISCLOSURE OF FINANCIAL INTEREST Physician ASC

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