Whether you are a physician, pharmacy, hospital, or other provider, you have undoubtedly faced complications in having your claims paid by a claims administrator at some point in time. Under Medicare, Medicaid, ERISA, and various other Federal and State statutes and their accompanying regulations, there are guidelines for administrative appeal processes which claims administrators must follow when dealing with payment disputes.
Regrettably, the proper processes are not always correctly followed by parties engaged in a good faith payment dispute. In order to increase the chance of a successful payment appeal, every provider should pay close attention to the notices received from a claims administrator, particularly related to timing of appeals. If there is no timing of appeal provided, request one in writing. Treat each appeal as if it will be reviewed by an objective third party, such as an Independent Review Entity, Administrative Law Judge, arbitrator, or the like, because it could eventually end up being reviewed as such down the road. One common pitfall is that a given provider did not maintain proper records of, for example, copayment collection or inventory purchases from duly accredited wholesalers, making it difficult for the provider to combat audit results or cure alleged claim defects. In some situations where the provider has such documentation, administrators will not even accept supporting documentation for reasons which may not be legitimate. Thus, when dealing with a claims administrator, always reduce conversations to writing whenever possible, and take copious notes whenever you are dealing directly with a claims administrator telephonically. If you continue to have trouble in getting the claims administrator to tender payment, it may be best to speak with an attorney to assist you with your audit appeal or payment dispute. Contact Frier Levitt today.
