texaslawyer.com Friday, March 24, 2017
Tips for Success: Resolving Your Provider/Payor Healthcare Dispute
By Adrienne Publicover
The fate of the Affordable Care Act may be the most significant healthcare issue facing 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 physicians and/or healthcare professionals 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 proceedings, both of which can be costly for all parties. However, with careful planning and communication, early mediation can lead to successful and more economically efficient resolution.
Here are a few tips for consideration.
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 collaboration between the parties and the mediator is a crucial element
to success. But with payor- The purpose of such laws is to
provider disputes, this is par- help ensure that medical ser-
vice providers are fully com-
First, these disputes generally pensated for their work within
involve multiple issues - both specific timeframes. However,
contractual and legal - as well the prompt pay statutes do not
as numerous claims. Identi- apply in every situation.
fying all the issues helps the For example, the Texas Prompt
skilled mediator craft a plan for Pay Act applies only to HMO's
and PPO's. It may not apply to
Moreover, these disputes self-funded ERISA plans, fed-
may involve multiple parties. eral employee plans and a few
It is important that all entities others.
responsible for paying money Moreover, the Act only
(or entitled to receive money) applies to "clean claims." Data
are brought into the process in contained in the claim must be
a timely manner so that global complete, legible and accurate.
resolution may be achieved. The claim generally must have
These may include parent cor- been submitted within 95 days
porations and subsidiaries, as of services rendered.
well as additional providers.
Late payment of these claims
may result in substantial mone-
2. What is the amount at tary penalties to the point where
settlement may be impacted.
It has been said before, but it Thus, it is important to ensure
bears repeating: mediation is that applicability of the laws
not the time for high level math. has properly been evaluated.
Issues such as pricing, reim-
bursement rates, any appropri- 4. Remain optimistic.
ate discount rates, etc. should be Your mediator should be pre-
resolved well in advance of the pared to engage early in the
mediation session. And relevant process. She should ask the
contracts, related documents important questions. Have all
and spreadsheets should be the issues been identified? Will
exchanged in a timely m anner. all necessary parties be present?
Have accurate calculations been
3. Is a prompt payment law completed and exchanged?
This information will assist the
Texas is one of many states mediator in crafting creative
which has a Prompt Pay Act. solutions.
Work with the other side(s) to share necessary information. Protective orders may be used to address privacy and confidentiality concerns.
Be open to joint sessions, not for the purpose of table pounding and argument, but to collaborate 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, preparation 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 market, she has successfully negotiated thousands of life, health and disability claims, ERISA matters, property damage, coverage issues, employment and personal injury claims. She may be reached at [email protected]
Reprinted with permission from the March 24, 2017 edition of the Texas Lawyer 2017 ALM Media Properties, LLC. All rights reserved. Further duplication without permission is prohibited. For information, contact 877-257-3382 or [email protected] # 651-04-17-02