How many times have you heard from an insurance company "Oh no, we can’t pay your claim because it is coded incorrectly according to Medicare." Or what about "You owe us money back because you violated the federal Safe Harbors." Or even "Your charges exceeded the Medicare allowable, so we will report you to the Insurance Commissioner." BS. Absolute BS!
Commercial payers (HMOs, PPOs and the like) are not Medicare. The federal regulations that apply to Medicare and Medicare patients don’t apply to commercial payers. Commercial payers knows this, but some of them take advantage of physicians’ fear to get them to back off of legitimate claims for compensation and even to get them to pay the payers money that is not really owed! It happens every day. And physicians are even more confused by the fact that their coders or coding consultants sometimes substantiate the managed care payers’ claims! But here’s the point to make: managed care is not Medicare. The same rules do not apply; so commercial claims cannot be viewed in the same way that Medicare claims are viewed.
The dirty little secret is that there is substantial confusion about the difference between commercial claims and governmental claims; and payers sometimes exploit the confusion to their benefit. Commercial claims are governed by (1) state law, (2) the rules and regs of each such payer, and (3) the terms of any contract to which the physician may be a party. Innocent and well-meaning consultants to physician sometimes practices try to fit square peg analysis of commercial claims into the round hole of Medicare claim compliance. They don’t fit!
Physicians must ensure they get the right advice. Ensuring someone is a "certified professional coder" is not enough. They have to engage people who can use the right analysis for each commercial payer and see those claims with the background of (1) the rules and regs of each such payer, (2) state regulations that may apply, and (3) the terms of any contract to which the physician is a party. The "Safe Harbors" and other lingo used by some commercial payers is a tactic to frighten physicians into backing off legitimate claims and even repaying the payer monies they are looking to recoup. Don’t fall for it!
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With over 20 years of healthcare law experience following his experience as legal counsel for the Florida Medical Association, Mr. Cohen is board certified by The Florida Bar as a specialist in healthcare law. With a strong background and expertise in transactional healthcare and corporate matters, particularly as they relate to physicians, Mr. Cohen’s practice immerses him in regulatory, contract, corporate, compliance and employment related matters. As Founder of The Florida Healthcare Law Firm, he has distinguished himself and his firm for providing exceptional legal services with the right pricing, responsiveness and ethics.
