Managed Care and Health Insurance Attorneys

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Are you having problems with your managed care or health insurance company?

Insurance providers use many methods in order to try to not pay doctors what they are owed. It may be a technicality—such as no date on the record—or a more serious discrepancy, e.g., if the doctor does not lay out a specific plan of care for the patient.

• Has the insurance company sent you a letter indicating they instituted a “peer review” through a peer review organization (PRO) against you and now refuse to pay your billing based on Act 6 of the Pennsylvania Financial Responsibility Law?
• Have you been denied payment for your services?
• Are your bills being refused due to level of care billed, medical necessity, no record date, no plan of care, or illegible records?
• Are you losing appeals?
• Are you currently under investigation for billing issues?
• Is the managed care plan using sampling methodology for overpayment recovery?
• Has the insurance company “extrapolated” their sample to recoup their overpayments?
• Has the insurer decided on future payment recovery to recoup their so-called overpayments?
• Are you having problems with “incentive programs”?
• What options do you have when managed care or health insurance companies challenge your billing?

These companies are allowed to use sampling methodology in their “overpayment recovery.” The insurance company often will extrapolate when coming to the amount of money that they believe is an overpayment. The insurance company uses a methodology to look at a small part of the bills and then decides what the actual overpayment is—based upon this extrapolation.

This methodology can be challenged successfully to reduce the amount of the alleged overpayment. Insurance companies also use incentive programs in order to try and have doctors reduce the care provided. These can also be challenged. Often the auditors who review these bills and these methods for insurance companies use flawed methods and analyses to come to their numbers.

Sometimes doctors will appeal these billing challenges on their own. But often it is a better idea to have an attorney experienced in dealing with managed care and health insurance companies to assist you.

For a law firm experienced in fighting the insurance companies on behalf of hard-working healthcare providers, please call us today at ThePhillyLawyers: 215-884-9300.

What is a peer review?

Sometimes the insurance company for patients injured in car accidents will institute a “peer review” under Act 6 of Pennsylvania Motor Vehicle Financial Responsibility Law (MVFRL), which permits insurers to contract with peer review organizations (PRO). The insurer has 90 days from the date receiving the bill from the provider to submit a challenge to the PRO who assigns a reviewer to give their opinion about whether the services provided were reasonable and necessary.

There is also an opportunity for the provider to discuss the case with the reviewer. Then the reviewer issues a report within 30 days after its receipt of the medical record documentation. If the PRO gives their opinion that the services were not reasonable and necessary, then the insurer can refuse to pay for those services. The provider then can challenge with peer review with a reconsideration or appeal the decision in court. If the provider is successful in the challenge, the insurer must pay to the medical provider the outstanding amount plus interest at the rate of 12%, as well as the costs of the challenge and all attorney fees.

For a law firm experienced in fighting against unreasonable peer reviews, please contact ThePhillyLawyers.

Patients:

• Are you having problems with your managed care or health insurance company?
• Is your health plan withholding payments due to services that are deemed “not medically necessary”?
• Are you forced to pay doctor bills that should have been paid by your health plan?
• Are you being investigated for healthcare fraud?
• Is your healthcare provider notifying you of coverage stoppage?

ThePhillyLawyers can help guide you through the healthcare maze and help you with your battles. We can assist medical providers and patients with all of your healthcare reimbursement issues. We will present a well-researched, organized defense, to stop insurance companies from taking your money or withhold payment. Whether you are a provider or a patient, we can help.

Call us today at ThePhillyLawyers: 215-884-9300.