4 Things Doctors Need to Know About Provider-Payer Disputes
Our healthcare environment becomes more complex every year. While your organization may feel comfortable handling some provider-payer issues in-house, many medical groups are discovering that the insurance companies and other payers are becoming more aggressive with cost-cutting tactics. Whether payers are reducing your payments under a “value-based care” model or disputing the necessity of care, you need an advocate who understands these complex disputes and your legal rights.
At Bryant Legal Group, we help physicians and healthcare providers throughout Illinois with their provider-payer disputes. Here are some of the essentials that every healthcare professional needs to know.
1. Provider-Payer Disputes Are on the Rise
According to Georgetown University’s Center on Health Insurance Reforms, there was a significant spike in payer-provider disputes in 2019, and the university’s experts don’t anticipate a slowdown anytime soon.
Healthcare providers are frantically trying to cut their skyrocketing costs while also appeasing the rising demand for access to care. Unfortunately, providers are caught in the crossfire.
For example, value-based care and payments, where providers get bonuses or higher compensation if they meet specific care metrics, are leading to more improperly denied payments. These innately subjective payment structures are prone to misinterpretation and often result in delays in payments and denied claims.
2. Post-Payment Audits Are Becoming More Common
Just as provider-payer disputes have become more common, so have post-payment audits. In a recent survey, about 25% of the participating hospitals reported getting between 500 and 2,000 audit requests per month.
During a post-payment audit, the payer may ask to review your patients’ medical records and other documentation, looking for potential overpayments and other errors. Then, the payer will aggressively demand repayment. However, mistakes occur during these audits, so never assume that the payer’s estimation is correct.
If your office is the subject of a post-payment audit, it’s best to contact an experienced attorney as quickly as possible. A lawyer can help you navigate the audit, assert your legal rights, and determine whether the payer’s demand for reimbursement is merited.
3. Provider and Payer Consolidation Lead to High-Stakes Disputes
Both providers and payers have been consolidating over the past decade. Medical groups are getting larger and larger, in part because consolidation relieves many of providers’ administrative burdens and lets them focus on their patients. Between 2013 and 2016, the number of practices with 100–500 providers in Chicago grew by 25%, while the number of small and mid-sized medical groups steadily decreased.
At the same time, healthcare insurers like UnitedHealthcare, Aetna, Cigna, and various Blue Cross Blue Shield entities have acquired the lion’s share of the healthcare insurance market in most states. Now, these companies are acquiring medical groups in an attempt to create vertically integrated health systems.
What does all this consolidation mean for provider-payer disputes? They’re now a high-stakes game. A provider-payer dispute involving a statewide or national healthcare organization can easily involve millions of dollars.
4. Mediation and Arbitration Can Streamline the Process, But They Also Carry Some Risk
Historically, litigation was common in provider-payer disputes. However, there has been a significant push towards alternative dispute resolution (ADR). Your participating provider agreement may contain ADR processes, including:
- Mediation: A specially trained professional guides the provider and payer through their negotiations, trying to identify common ground and potential areas for compromise.
- Arbitration: Each side presents its case to a panel of trained arbitrators, who then make recommendations or issue a binding order.
While ADR can help narrow a provider-payer dispute, you need to proceed with caution, especially if your participating provider agreement mandates binding arbitration or mediation. Under these circumstances, the mediator or arbitrator’s decision will be final, and you typically won’t be able to file a lawsuit.
If you’re facing binding arbitration or mediation, you need an experienced healthcare lawyer at your side. A team of lawyers will represent the payer, and you need to have the same level of protection (or more). An attorney can help you present your evidence and legal claims, highlight weaknesses in the payer’s arguments, and negotiate on your behalf.
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Curran, E. (2020, Feb.) Payer-Provider Contract Disputes Dominate Headlines in 2019, With No Signs of Slowing Down. Center on Health Insurance Reforms. Retrieved from http://chirblog.org/payer-provider-contract-disputes-dominate-headlines-2019-no-signs-slowing/
Research: The Impact of DRG Audits on Provider Sentiment and Abrasion. (2020, January 9). Change Healthcare. Retrieved from https://learn.changehealthcare.com/payment-accuracy/payment-integrity-program-ebook
State of the Chicago Health Care Industry. (2018, March). Health Care Council of Chicago. Retrieved from https://matter.health/uploads/hc3_whitepaper_digital.pdf
The content provided here is for informational purposes only and should not be construed as legal advice on any subject.