Out-of-Network (OON) healthcare providers face unique issues in obtaining proper payment from insurance companies even when their patients have healthcare coverage for OON services. Frier Levitt utilizes state and federal laws to ensure OON providers are properly and timely paid for services rendered to patients.
Frier Levitt assists OON providers obtain proper reimbursement through:
Practice Review and Education
Providers with a properly vetted Designated Authorized Representative and Assignment of Benefits forms as well as Standard Operating Procedures can prevent a majority of OON reimbursement challenges. Implementation of OON industry best practices should be coupled with proper office staff education to enable providers and their staff to obtain and document accurate, verifiable, and reliable records of any prior authorization/approval or any representations made by payors and their administrators during treatment for a given patient.
Frier Levitt works with OON providers to develop these forms and procedures, in addition to office staff training to create positive change in OON documentation, billing and collections.
Out-Of-Network Claims Administrative Appeals
Patient benefit plans typically require OON providers and their patients to exhaust their “administrative appeals” with the relevant claims administrator (i.e. Aetna, UnitedHealthcare, Blue Cross Blue Shield). During the appeals process, OON providers and their patients are entitled to receive a full and fair review of all payment claims or adverse benefit determinations as well as fair and reasonable pricing for defined OON benefits. Notwithstanding these legal obligations and other fiduciary duties imposed on plan and plan administrators, many insurance companies instead make decisions that benefit their bottom line.
Frier Levitt has extensive experience navigating the nuanced OON administrative appeals process to obtain settlements or set the stage for successful litigation.
Litigation
Should efforts to obtain a reasonable reimbursement not succeed in the administrative appeals process, the claims may proceed to litigation. Frier Levitt has developed multiple litigation strategies to obtain proper reimbursement, including asserting claims under state and federal law. Our team offers services to OON healthcare providers looking for assistance in with reimbursement issues under Alternative Fee Arrangements (AFA), flat fees, and contingency fee models.
Frier Levitt provides strategic, industry-focused legal counsel tailored to your needs. Contact our team today to learn how we can help you.