Tips for Success: Resolving Your Provider/Payor Healthcare Dispute
Source: Texas Lawyer
Date: March 24, 2017
Adrienne Publicover, Esq.
The fa Te of The affordable Care act may be the most sig- nificant healthcare issue fac- ing our country. regardless of the outcome, it is clear that the industry is undergoing dynamic growth and change. With that change comes litigation in all shapes and sizes – patient claims against hospitals and nursing homes; conflicts between phy- sicians and/or healthcare pro- fessionals and the hospitals in which they work; and financial disputes between payors and providers. Claims between payors and providers have resulted in significant amounts of civil litigation and arbitration pro- ceedings, both of which can be costly for all parties. how- ever, with careful planning and communication, early media- tion can lead to successful and more economically efficient resolution. here are a few tips for consid- eration. 1. Have you identified all the issues and the necessary parties? benjamin franklin (and sub- sequently Winston Churchill) said, “If you fail to plan, you are planning to fail!” as with any mediation, advance collabora- tion between the parties and the mediator is a crucial element texaslawyer.com | Friday, March 24, 2017 w By Adrienne PuBlicover Tips for Success: Resolving Your Provider/Payor Healthcare Disputeto success. but with payor- provider disputes, this is par- ticularly true. first, these disputes generally involve multiple issues - both contractual and legal - as well as numerous claims. Identi- fying all the issues helps the skilled mediator craft a plan for resolution. Moreover, these disputes may involve multiple parties. It is important that all entities responsible for paying money (or entitled to receive money) are brought into the process in a timely manner so that global resolution may be achieved. These may include parent cor- porations and subsidiaries, as well as additional providers. 2. What is the amount at stake? It has been said before, but it bears repeating: mediation is not the time for high level math. Issues such as pricing, reim- bursement rates, any appropri- ate discount rates, etc. should be resolved well in advance of the mediation session. and relevant contracts, related documents and spreadsheets should be exchanged in a timely manner. 3. Is a prompt payment law in play? Texas is one of many states which has a Prompt Pay act. The purpose of such laws is to help ensure that medical ser- vice providers are fully com- pensated for their work within specific timeframes. however, the prompt pay statutes do not apply in every situation. for example, the T exas Prompt Pay act applies only to hMo’s and PPo’s. It may not apply to self-funded erISa plans, fed- eral employee plans and a few others. Moreover, the act only applies to “clean claims.” data contained in the claim must be complete, legible and accurate. The claim generally must have been submitted within 95 days of services rendered. late payment of these claims may result in substantial mone- tary penalties to the point where settlement may be impacted. Thus, it is important to ensure that applicability of the laws has properly been evaluated. 4. Remain optimistic. Your mediator should be pre- pared to engage early in the process. She should ask the important questions. have all the issues been identified? Will all necessary parties be present? have accurate calculations been completed and exchanged? This information will assist the mediator in crafting creative solutions. Work with the other side(s) to share necessary information. Protective orders may be used to address privacy and confi- dentiality concerns. be open to joint sessions, not for the purpose of table pound- ing and argument, but to col- laborate on resolution strategies. The parties are the ones closest to the dispute and play a valuable role in successful settlements. finally, remain optimistic. With careful planning, prepara- tion and open dialogue between the parties, you will have set the stage for successful resolution. Adrienne Publicover, Esq. has counseled domestic insurers and brokers in litigation matters in state and federal courts. Having also practiced in the London mar- ket, she has successfully negoti- ated thousands of life, health and disability claims, ERISA matters, property damage, coverage issues, employment and personal injury claims. She may be reached at apu- email@example.com Reprinted with permission from the March 24, 2017 edition of the Texas La wyeR © 2017 aLM Media Properties, LLC. all rights reserved. Further duplication without permission is prohibited. For information, contact 877-257-3382 or firstname.lastname@example.org. # 651-04-17-02 w