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Phia Group Media


Usually and Customarily Denied

By: Jon Jablon, Esq.

An increasingly common problem that self-funded plans face is that plans subject to network agreements pay claims correctly and timely and at the negotiated rate, but when the claim is submitted to stop-loss, stop-loss denies a portion of the paid claim as excessive compared to the carrier’s U&C provision.

The first question a plan should ask is whether the carrier was correct in denying the claim. For instance, if the stop-loss policy defines U&C as the prevailing charge in the area, the carrier has limited its ability to reduce the claim except based on the prevailing charge in the area, so the basis for reducing the claim is severely limited.

To contrast, if the stop-loss policy defines U&C as the lesser of the prevailing charge in the area or, say, 150% of Medicare – then the carrier has the right to perhaps reach a lower determination of payability.

This might seem like a question that shouldn’t need to be asked – and we agree! – but there are so many moving parts in the self-funded industry and so many differing interpretations of contracts that it makes sense to cover all possible bases.

No matter who the carrier is, we urge health plans to not make any assumptions about what will or will not be covered. Since many stop-loss policies contain their own definitions of U&C, a health plan should coordinate with its stop-loss carrier as early in the policy year as possible (or even, ideally, prior to signing) to determine how the carrier will treat network payments in terms of U&C.

We urge health plans to learn from others’ mistakes, and make sure all the relevant contracts align before signing them. The questions of how a stop-loss policy defines U&C and how the carrier will treat network rates are important parts of the shopping-around process!



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