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As you know, there have been a lot of out of network providers facing recoupments, refund demands and so called “special investigations“ (“SIU”) from insurance payers and health plans. This is a serious problem that we are looking to address on behalf of our out of network clients. We have been providing our audience and clients with tips to assist in their fight of these recoupments (take backs) over the past year. This article attempts to dig a little deeper into this issue and evaluate recent, relevant cases in the area of recoupments.
The net effect of this coordinated insurer movement is that out-of-network reimbursements will remain unreasonably low and uncustomary. At least one legislator is getting the message. Hats off to New York State Sen. Kemp Hannon, who is proposing legislation to compel New York-based insurers to reimburse out-of-network claims using the Fair Health database. I urge you to review Sen. Hannon’s proposed Senate Fair Health Bill S5068. Please get the word out. Physicians and other healthcare institutions need to alert their medical societies, the American Medical Association and their own legislators and representatives to get similar legislation passed in New York and across the United States.
What you should do to receive timely payments from providers, recover revenue more efficiently, and compliance strategies to hold issuers more accountable.
As you know, we have been carefully reviewing and analyzing recent case law and have found a very interesting case dealing with remedies under ERISA for denial of benefits. We have written about other ERISA issues in the past. Recently the 6th Circuit in; Todd Rochow et al. v. Life Ins. Co. of North America, case number 12-2074, (6th Cir. 2013); ruled that being awarded damages, injunctions and disgorgement under both §502 (a)(1)(B) and §502 (a)(3) is permissible. A plan beneficiary need not limit his/her damages to the plan benefits only.
Are you waiving co-payments? You could be at risk of an audit or fraud claims!
It is imperative that the healthcare system or medical practice, provider and revenue recycle administrators familiarize themselves with the various laws and other responsibilities of the various managed care organizations. Then hold these payors accountable to the law. Remember, the "power" is with you.
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