Developing Successful Strategies for Handling Payor vs. Non-Par Provider Reimbursement Disputes
Berkeley Research Group (Tampa, FL)
Blue Cross and Blue Shield of Louisiana (Baton Rouge, LA)
John T. Fogarty
Manatt, Phelps & Phillips, LLP (Los Angeles, CA)
Matthew A. Heinle
Mercy Medical Center (Canton, OH)
Jason Daniel Joffe
Squire Patton Boggs (US) LLP (Miami/West Palm Beach, FL)
- 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
- 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