When providers face disputes with health plans regarding denied or underpaid claims, it can help to use a third-party law firm to resolve the issue, advises Lyman Sornberger, vice president of client development at Charles J. Hilton and Associates law firm.
"Healthcare providers should strive to effectively use law firms for disputes on underpaid or unpaid insurance claims," he told Becker's Hospital Review. "Many health plans nationwide do not always follow proper claims procedures when making decisions to reimburse or deny a medical service."
These decisions are governed by the federal Employee Retirement Income Security Act, but the problem,Mr. Sornberger said, is providers are not always familiar with these regulations. This is where a third-party law firm could step in.
"During a dispute, the legal firm should understand the provider's appeal rights with the specific health plan and exhaust them prior to initiating civil action. Understanding each ERISA claim procedure that the health plan violates is crucial to reimbursement," said Mr. Sornberger.
If you would like to share your RCM best practices, please email Kelly Gooch at kgooch@beckershealthcare.com to be featured in the "RCM tip of the day" series.
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