REIMBURSEMENT DISPUTES

1. REIMBURSEMENT DISPUTES Charles “Scott” Nichols Strasburger & Price, LLP 1401 McKinney St., Suite 2200 Houston, Texas 77010 713.951.5621 scott.nichols@strasburger.com

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

3. Out of Network • Usual and customary / UCR • Payer tricks • Examples

4. 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.

5. 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.

6. 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

7. ERISA • Any group health plan • Fully insured or employer funded

8. 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!

9. 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

10. DISCLOSURE OF FINANCIAL INTEREST • Physician • ASC

11. YOU CANNOT WAIVE CO-PAY AND/OR CO-INSURANCE Financial policy onboard

12. FALSE CLAIMS ACT Government funded Payor – extra consideration to what you do

13. THANK YOU