MEDICAL FEE DISPUTES

RPC works with both health care providers and third party payors in medical bill disputes. Billing for health care services is a complex process that involves thousands of codes for procedures, modifiers, diagnoses, places of service, and special circumstances. This complexity is multiplied by the thousands of payment policies that may be applied to a bill by a third-party payor. To further complicate the payment process, the payment policies for each government and commercial payor are different.

With the complexity of the medical billing and payment process it is not surprising that payment disputes frequently arise between healthcare providers and health insurance plans. Some disputes are covered by contracts between the parties. Others are governed by state laws. Others arise because of the lack of any black-letter law determining the payment due. These disputes often involve claims for several million dollars in additional payment for past services. Decisions in these cases can affect millions of dollars in payment for services in the future.

Some disputes are straightforward and can be resolved in the normal course of business. However, litigation or arbitration is necessary to resolve others, and these disputes tend to require significant statistical and clinical analysis to determine liability and to calculate damages. In these cases RPC can be a party or an attorney to determine if damages, penalties and interest are owed.

RPC has over 20 years direct experience in medical bill review, utilization review, and the analysis of medical fee disputes for government agencies, health care providers and third party payors. Our team of economists, health care administrators, accountants, nurses and physician advisors has analyzed billing disputes involving a wide range of health care services, health care providers and insurance programs. RPC can provide analysis of individual bills, payment policies and the payment process including the following:

• Compliance with provider contracts
• Compliance with state fee guidelines and payment policies
• Definition of usual and customary fees
• Compliance with state utilization review laws
• Compliance with uniform billing and coding standards
• Reasonable documentation of services
• Compliance with reconsideration and appeal procedures

Texas and some other states have passed “Prompt Pay Acts” that apply to a payor’s compliance with the terms of the PPO contract negotiated with a healthcare provider. Relatively small underpayment of amounts due or delays in payment can generate substantial damage awards. Where these acts apply it becomes even more important for each party in the litigation to have qualified experts to analyze the data to determine what, if anything, is owed. RPC can help a payor or health care provider to assess its position and its potential gain or exposure.

For sample RPC reports and professional references please contact Ron Luke at (512) 371-8000