Ambulatory surgery centers, hospitals and other providers are increasingly encountering more disputes with out-of-network payors, and knowing where those disputes stand in the court of law could give other providers a sense of what they should do if they have similar issues.
At the 19th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 25, Daron Tooch, JD, attorney with Hooper, Lundy & Bookman, explained some of the major disputes he's seen with OON payors and providers.
One of the major issues that still plagues OON ASCs and other providers is payments that involve usual, customary and reasonable charges. Many ASCs, hospitals and physicians are going OON because regular health insurer rates are "too low to make a living," Mr. Tooch said. Health insurers are now balancing this trend out by adjusting UCR methodologies to lower payments.
"In the past, health plans were pretty good based on a provider's charges," Mr. Tooch said. "But recently, health plans are revising methodologies to come up with different UCR payments."
Recoupments from health insurers are another major dispute between OON providers and payors, he said. Payors are conducting internal audits to see if they overpaid providers, and in many instances, they are recouping claims off a similar strategy seen with Medicare Recovery Auditors.
Finally, Mr. Tooch emphasized that the Employee Retirement Income Security Act is a "friend" for ASCs and other providers. ERISA is the federal law that regulates the operation of health plans. "We're having a lot of success, under ERISA, getting claims paid," he said.
At the 19th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 25, Daron Tooch, JD, attorney with Hooper, Lundy & Bookman, explained some of the major disputes he's seen with OON payors and providers.
One of the major issues that still plagues OON ASCs and other providers is payments that involve usual, customary and reasonable charges. Many ASCs, hospitals and physicians are going OON because regular health insurer rates are "too low to make a living," Mr. Tooch said. Health insurers are now balancing this trend out by adjusting UCR methodologies to lower payments.
"In the past, health plans were pretty good based on a provider's charges," Mr. Tooch said. "But recently, health plans are revising methodologies to come up with different UCR payments."
Recoupments from health insurers are another major dispute between OON providers and payors, he said. Payors are conducting internal audits to see if they overpaid providers, and in many instances, they are recouping claims off a similar strategy seen with Medicare Recovery Auditors.
Finally, Mr. Tooch emphasized that the Employee Retirement Income Security Act is a "friend" for ASCs and other providers. ERISA is the federal law that regulates the operation of health plans. "We're having a lot of success, under ERISA, getting claims paid," he said.
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