Quantum Legal represents and partners with experts in the area of individual healthcare provider clients against healthcare insurers.

Medical Necessity Denials by Healthcare Insurers

Healthcare insurers deny reimbursements based on medical necessity for a host of reasons which have nothing to do with actual medical necessity, such as the desire for cost savings. These dete1minations can be appealed, mediated, arbitrated, and litigated.

Experimental and Investigational Denials

Healthcare insurers also deny reimbursements based on their own non-medical definitions of experimental and investigational, relying on statements in nonpublic bulletins they create, and on decisions by their medical directors. These decisions can be analyzed, researched, appealed, mediated, arbitrated, negotiated and litigated.

Repayment Demands, Recoupments and Offsets

Healthcare insurers often initially pay claims and then decide not only that they want the money back as to a specific claim, but that they want all the money they paid out in the past for the same procedure or supply. They conduct an “audit,” demanding billing records from providers, and they extrapolate to make a repayment demand often representing the entirety of the provider’s claims payment history. When repayment of demanded amounts is not immediately forthcoming, healthcare insurers offset the full amount they claim from all other amounts they owe, even when these claims and services have nothing to do with the claims originally at issue.

Repayment demands, recoupments and offsets can and should be challenged. In such circumstances, competent legal representation may be critical because they may have to be challenged or part of high-level negotiations.

Failure to Reimburse According to the Fee Schedule

Hospitals negotiate a set amount per CPT code, procedure, service, or bed day, and with respect to hospital-based physicians, according to CPT codes. However, healthcare insurers often fail to reimburse according to the proper fee schedules, either further discounting the amount or inputting an older version into their claims processing system. All of this must be reviewed closely and not simply accepted as the “allowed amount.”

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