As many know, out-of-network providers have much different appeal rights with commercial plans than in-network providers. It is important to understand each health plan’s appeal procedure as well as time requirements for an appeal may vary. However, the appeal process is still one of the most important tools providers have to get paid in the current environment of reduced reimbursements, caps on the number and frequency of services, bundled payments based on specific codes, delayed payments, daily errors in claims processing leading to denied claims, claw backs, and the list goes on.
Presently, payment for healthcare services is governed by the use of thousands of codes which describe a specific medical activity. Payment is made on a fee for service basis based on the medical activity or service rendered. Capitation payments are also used in managed care in which providers are paid a lump sum per patient regardless of how many services the patient received. Increasingly, payment is being shifted to an episode of care concept and used interchangeably with bundled payments or case rate payments. These are generally defined on the basis of expected costs for clinically defined episodes of care. An episode of care can range from a few days to a year and the patient will receive care from multiple providers who treat a particular condition over the length of time it takes to address the specific ailment. An episode of care payment is a single price paid for all the services needed by a patient.
Health law is the federal, state, and local law, rules, regulations and other jurisprudence among providers, payers and vendors to the healthcare industry and its patient and delivery of health care services; all with an emphasis on operations, regulatory and transactional legal issues.