Managed Healthcare Law

It is our goal to provide our clients in the healthcare field with Benefit, Value and Results. We offer services that accomplish those goals as follows:

  • Accountable Care Organizations – these are cutting edge entities which will be created as a result of Health Care Reform which will permit you to explore providing greater care, at less cost.  We will assist you in navigating through the new laws so as to take advantage of the opportunities created by these new types of organizations.
  • Business Transactions & Organizations – We will assist you in negotiation and preparation of contracts with respect to mergers with other groups or providers so that you can get the best return on your investments.
  • Litigation, Mediation, Arbitration – We can assume role of lead attorneys with regard to any existing litigation matters you may have, and navigate you through the difficulties engendered by the legal process .
  • Managed Care – negotiation of provider agreements with insurers/payors so that you can obtain the best rates of reimbursement available.
  • Patient Privacy and Security Law – HIPPA compliance so as to ensure you avoid potential pitfalls and fines.
  • Provider Reimbursement & Payment –  Lawsuits to recover money you have earned and are due as a result of underpayment by payors-insurance companies, for example:
    • Non-participating provider litigation, such as “usual, customary and reasonable charges”
    • Participating provider litigation- failure to honor pre-certification
    • Denials based on issue of medical necessity
  • Stark and Anti-Kickback – We can help you navigate through issues that arise when doctors groups enter into relationships with other health care groups so as to minimize costs.
  • Employment issues- We can assist you with a wide array of employment related headaches and minimize risks of lawsuits by providing you guidance and expertise in areas such as complaints of discrimination and harassment.

Tasks that TKB can undertake for clients include ascertaining and analyzing the efficiency of billing and reimbursement practices of our clients and the insurers (payors) in which the claims are submitted.

DOWNCODING and BUNDLING

One of the goals of any task undertaken will be to identify and eliminate inappropriate downcoding and bundling practices by insurers.

An insurer employs a “downcoding” technique in its calculation of the amount due for a covered service when a provider uses a specific Current Procedural Terminology “CPT” code to describe the particular medical service or procedure and the insurer then reclassifies that CPT code to a less expensive CPT code.

An insurer uses a “bundling” technique in its calculation of the amount due for a covered service when the provider uses two or more CPT codes to describe two or more procedures performed and the insurer then combines those CPT codes into a single CPT code that is less expensive than the combination of the multiple CPT codes.

ANALYSIS OF CLAIMS

Taking a sampling of claims by insurer, we can review the claims to ascertain if there any of the following:

Inconsistent applications of claim payment policies and practices including payment variations for like procedure codes for similar services as well as inconsistent application of claims adjudication rules. This process will highlight and identify instances of downcoding and bundling in contravention of accepted custom and practice.

Inconsistencies in billing submittals and coding practices of clients. Despite their best efforts our clients sometimes have practices that are counter-productive to the receipt of full payments. Our review will determine if there are billing practices employed by clients that contribute to underpayment or to the likelihood of denials.

Inconsistencies in payment of interest, penalties by insurers and whether required full charges were paid to clients for cases in which claims were not processed timely under the requisite claim procedure for notifying a claimant of a benefit determination under state and federal regulations.

OUT OF NETWORK ANALYSIS

In addition to a review of par agreement insurers, an analysis of claims submittals to out of network payors could be undertaken. Amongst the issues that can be reviewed:

Review of client’s appeal process for non-participating providers in the context of claim payment. This analysis could determine whether more pro-active processes can be employed to advance reimbursement, or to set up clients for dispute resolution action, such as litigation for claims improperly denied.

Comparisons between Usual and Customary (UCR) rates for clients can be compared to the rates of payment made by non-contracted payors to other providers for similar procedures and with similar associated medical risk exposure in comparable geographic regions. Included in that process would be an evaluation of the reasonableness of those rates of reimbursements, relative to various industry benchmarks including RVU’s