What is Denied Claims Litigation?
Claims denied improperly by managed care payers fall within the scope of the provider participation agreement signed by the provider and payer. Therefore, any wrongly denied claims are subject to the terms of the signed agreement, as well as to applicable laws relating to contract breaches.
More specifically, a health plan’s breach of its own contract is subject to the dispute resolution terms of the signed contract, which allow for either a lawsuit or arbitral demand to be filed against the payer.
Why Significant to Providers?
Even if the contract or its related provider manual spells out specific terms not met by a provider, some denials may be unenforceable as illegal penalties. (See Disproportionate Forfeiture blog article.)
Doctors and hospitals often write off tens of thousands of dollars – and sometimes millions of dollars. Healthcare providers who have rendered valuable services to a health plan’s members should not give up on improperly denied claims.
What can Anderson & Quinn Do?
Anderson & Quinn evaluates denied claims against the terms of the provider contract and helps our clients determine the next steps in proceeding against a payer’s improper denials.
Fact questions like prior authorizations, and legal questions like penalties are reviewed and evaluated by Anderson & Quinn. Published clinical criteria commonly employed by health plans are vetted against the prevailing community clinical and legal standards. (See Milliman Criteria blog article.)
When warranted, a lawsuit or arbitral proceeding is filed by Anderson & Quinn on behalf of the provider. The question of coverage is thus brought to a judge or arbitrator, not someone in the health plan.
Anderson & Quinn’s history of service to healthcare providers is based on these important understandings of managed care law, and we have helped healthcare providers recover millions of dollars in improperly denied claims.
