Managed Care: Prompt Payment, OON Payment, RBRVS-Based Fee Schedules and Appeals


Prompt payment by managed care organizations is once again a hot topic of debate as revisions of current law and regulations deals with claim submission deadlines, recoupment practices, prompt pay penalties, eligibility verification and underpayments.  Out-of-network providers scored a legislative victory as Medicaid managed care organizations will have to pay them regular Medicaid rates if use of their services exceeds new benchmarks.

Physicians should be careful that a fee schedule description based on Medicare RBRVS reveals the actual amount of payment. 

All providers should be examining their payments and claim denials and using current laws, regulations and cases to support their appeals of underpayments, late payments and adverse clinical decisions.  Our list of legal reminders are from actual matters we have handled for our clients.

This Client Alert presents information on managed care contracting, reimbursement and appeals that should be valuable to the health care provider who desires to assure compliance by managed care organizations with prompt payment, deadlines and penalties, payment formulas and appeals of denied claims.

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