Health Provider Payment Disputes

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. However, the impact of these disputes is not limited to past damages as decisions can also affect millions of dollars in payment for services in the future.

Analysis of Payment Disputes

RPC has over 20 years direct experience in medical bill review and utilization review. Our team of economists, healthcare administrators, accountants, nurses and physician advisors has analyzed payment disputes involving a wide range of healthcare services, healthcare providers and insurance programs. RPC can provide analysis of individual bills, payment policies and the entire 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