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Monthly Medical-Legal Roundtable – The Managed Care Settlements, September 2007 Presented by Heather Skelton, Attorney at Law


  • Retroactive relief settled (Submit claim for by October 19th), Prospective relief still in mediation.

Per Carol Scheele, more to come in early 2008.

  • Complaints of unfair and deceptive practices include:

    • o

      Bundling, downcoding, failure to recognize modifiers, unjustifiably refusing to pay

      • o

        Denying for medically necessary claims with no clinical review

      • o

        Inefficient administrative system designed to frustrate payment, redundant and excessive

requests for medical recrods, failure to explain payment denials

  • o

    Refuses to honor eligibility verifications

    • o

      Time consuming appeals process that discourages legitimate appeals

    • o

      All products clause

    • o

      Etc, etc. etc.


  • By signing an agreement inconsistent with the terms of the settlement agreement, you may be waiving the protections you are entitled to. This applies to all settlement agreements. In the packet is some suggested language to add to your contracts.

  • Quite a few coding rules are required

  • Physician fee schedules shall be made available via the Internet and can only be changed once a year

  • Physicians shall receive 90 days’ advanced written notice of material adverse changes

  • Payment policies will be consistent across all products and claim systems

  • Copies of contracts will be provided to physician upon written request

  • Clean electronic claims shall be paid within 15 days and 30 days if they are paper claims. Interest will

be prime or 8%

  • Retroactive recoupment is limited to 24 months and there shall be 30 days’ notice.

  • Arbitration fees are capped at $1000 for small groups or solos.

  • New physicians shall be credentialed within 90 days.

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©2007 Heather Cook Skelton, Attorney www.doctorslawyer.com

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