Fee Negotiations & ERISA Claims

Fee Negotiations & ERISA Claims

The Nan Gallagher Law Group litigates denied medical claims. These generally fall into one of the following categories:

High Dollar Claims for Single Patients – These claims arise in a number of situations. They can be patients with acute, severe conditions such as accident victims, premature babies or stroke victims. Or these claims can arise out of treatment to patients with chronic conditions that involve extended and/or intensive care such as cancer or transplants.

Patterns of Denial for the Same Types of Claims Involving Multiple Patients – These claims arise when the Firm has been retained by healthcare facilities or physicians groups. The Firm has litigated or arbitrated many cases where insurers or self-funded employer plans reduce or deny payment on a certain type of claim or procedure and that practice violates the language of the insurance policy, self-funded plan, managed care contract or industry standards. The reductions or denials may also violate the requirements of federal or state statutes.

Usual, Reasonable & Customary Charge (UR&C) Claim Denials – One specific category of payment reduction that the Firm has pursued successfully is to prevent the use of “usual, reasonable and customary charge” claim denials by insurers of self-funded employer plans. This tactic to reduce or deny payment is becoming increasingly popular as a way to try to save payors money and, in the process, shortchange health care providers and patients.

Often, insurers will retain the services of an outside consultant or company to “analyze” the bill and argue that there has been improper billing or overcharging by the provider. The consultant or the payor then unilaterally cuts the reimbursement to the healthcare provider. In our experience, this practice usually violates the terms of the managed care contract, insurance policy or the documents under which the self-funded plan is operated.

A variation on this theme is when the consultant contacts the provider and offers to pay a discounted amount, usually 5 – 15% off the billed charges, to be sent within a short time frame, but on the condition that the provider does not balance bill the patient. Sometimes the dollar amount of the reduction in payment is large; however, usually the reduction on any one patient is not so huge that the provider feels that it has many options other than to accept being nickeled and dimed. In fact, there is usually no justification for the request for this type of discount and providers who agree to this improper demand simply give money away and reward bad behavior by payors and their consultants.

With competent legal counsel, healthcare practitioners and entities can challenge and prevent these abusive practices.

In addition, The Nan Gallagher Law Group assists individual practitioners and medical practices in negotiating Out-of-Network fees with commercial payors. The Firm also negotiates In-Network status for healthcare providers working diligently to achieve competitive fees.

Moreover, the Firm has just launched its Gauntlet Program, providing impeccable arbitration and appeal services to Out-of-Network physicians and medical practices in the New Jersey/New York Metropolitan area.