Frier Levitt has secured a settlement of over $200,000, on behalf of an infusion pharmacy, related to years’ worth of unpaid claims submitted to a major medical health plan, for which the plan failed to take due responsibility. Over the past few years, the plan had made major changes to its contracts, forcing pharmacies to use a third-party administrator to submit claims, but providing unclear and contradictory instructions to pharmacies regarding how to submit claims for out-of-state patients or for patients receiving infusions within infusion suites. Moreover, even when the pharmacy submitted claims as instructed, such claims were often rejected and the pharmacy was told to file the claim with a different plan, which would, in turn, send the pharmacy back to the original plan. As a result, the pharmacy had significant claims that remained unpaid and outstanding, and required Frier Levitt’s assistance.
Frier Levitt attorneys raised a dispute with the plan and, after significant negotiations between the parties, Frier Levitt secured the settlement for the pharmacy without the need for litigation.
This kind of underpayment or non-payment of claims is, unfortunately, not unusual for infusion and specialty pharmacies providing out-of-state and/or out-of-network services to plan beneficiaries. Plans often institute opaque claims filing schemes seemingly designed to make processing such claims more difficult, or they may place certain out-of-network providers on a “pre-payment review” or other punitive scheme that delays or, in some cases, denies payment for services rendered. Consequently, providers can have potentially millions of dollars in claims unjustifiably withheld. Pharmacies providing these services should be aware that this is a common problem, and that experienced healthcare counsel can help.
Frier Levitt’s Pharmacy and Litigation practice groups have vast experience with payor related problems and can often connect with payors to resolve these issues before cash flow becomes an issue. Our attorneys are knowledgeable of pharmacy billing practices and payors’ specific requirements for out-of-state and out-of-network claims, and can step in to resolve such disputes in pharmacies’ favor. Contact Frier Levitt to learn more.
