The Phia Group was engaged by a captive insurance company to provide assistance with a medical provider that had been paid its full billed charges in error This particular captive manager was given The Phia Group’s name by a mutual partner, after the captive manager expressed a desire to engage a firm of experienced health care attorneys. In this case, the captive manager sought to utilize our medical bill negotiation service with respect to out of network insurance benefits provided by a non-ERISA plan, governed by state law. This particular plan utilized a narrow network, but any provider not covered by that network was subject to benefits based on Medicare based pricing – a form of reference based pricing. The health plan calculated its usual, customary & reasonable fees at a level approximately 30% of the provider’s billed charges. The captive manager’s concern was that if the plan had to pay more money to settle the claim on the back-end, the captive would be on the hook for anything denied by stop-loss in this particular arrangement.
The Phia Group engaged the medical provider. The provider argued that its usual & customary fees were exactly the amount that it had billed and received – and that the amount of benefits that the plan had re-calculated was not supported by the Summary Plan Description or the Summary of Benefits & Coverage – and accordingly, that this self-insured health plan was unreasonably trying to force the provider to refund its reasonable and appropriate healthcare fees. The Phia Group countered these arguments with arguments based on fair market value, health plan limitations, and potential balance billing issues the provider would face if it chose to pursue the patient. The Phia Group, after weeks of arguments back and forth, made it clear to the provider that what it had billed was inappropriate, and what it accepted as payment was incorrect. The Phia Group came to an agreement with the provider; for accounting purposes, the provider would refund the entire amount paid, and the plan would then re-issue a certain agreed-upon level of benefits, to complete the overpayment request.
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