Developing Successful Strategies for Handling Payor vs. Non-Par Provider Reimbursement Disputes

May 16, 2019 10:30am

Mark Abernathy
Managing Director
Berkeley Research Group (Tampa, FL)

Jessica Chapman
Litigation Counsel
Blue Cross and Blue Shield of Louisiana (Baton Rouge, LA)

John T. Fogarty
Manatt, Phelps & Phillips, LLP (Los Angeles, CA)

Matthew A. Heinle
General Counsel
Mercy Medical Center (Canton, OH)

Jason Daniel Joffe
Squire Patton Boggs (US) LLP (Miami/West Palm Beach, FL)

Disputes with non-par providers in both the emergency and nonemergency context are perhaps one of the greatest challenges that the managed care industry is presently facing. This session will help you address these disputes in both the emergency and nonemergency context.   Emergency context
  • Exploring the “greater of three” and typical disputes in this arena
  • Devising best practices for handling claims brought by out of network providers indicating that they were promised a particular preauthorization rate Developing defense strategies for disputes with non-contracted hospital(s) or medical group
    • What comes up in these cases?
    • What is the focus when determining reasonable value?
    • What expert testimony is needed?
    • What evidence is necessary?
  • Exploring defenses against arguments put forth by providers including:
    • The provider had to treat because it was an emergency situation
    • Various state statutes and ACA demand that a provider treats in emergency situations
  Non-emergency context
  • Addressing customer service representations regarding coverages
    • Developing best practices for handling communications with providers during preauthorization process
    • Suggested ways for MCOs to train and monitor how their customer service addresses pre-authorizations and reimbursement discussions