Friday, April 24, 2009

Recovering the Usual and Customary Rate- What the Healthcare Provider Should Know

The settlements reached earlier this year between New York Attorney General Andrew Cuomo and a group comprised of the largest health insurers in the United States have prompted a series of lawsuits throughout the country against major health plans such as Wellpoint, AETNA, and Cigna. A summary of this litigation can be found on this website. Essentially, the lawsuits claim that companies utilizing the Ingenix database have inappropriately manipulated the level of reimbursement paid to providers for out of network medical care to the detriment of members and providers.

When a provider treats a patient needing emergency medical services who subscribes to a health plan that is not contracted with the provider, there is no set rate at which the provider should be paid. Many statutes provide that in this situation the provider is to be reimbursed at the "usual and customary rate." In Florida, for example, according to Florida Statutes section 641.513(5), the plan must reimburse the provider at the lesser of the provider's billed charges, the agreed upon rate, or the usual and customary rate. But few, if any, define what "usual and customary" means or how it should be calculated, and as a result, providers and plans often disagree as to the appropriate level of reimbursement.

The most recent lawsuits should demonstrate to providers of all sizes that they do have recourse when they are being underpaid by one or more Managed Care Organizations. The Healthcare Reimbursement and Latest News sections of our website have more information on how consulting an attorney can be of benefit.

Tuesday, April 21, 2009

HIPAA and President Obama's Economic Stimulus Package

President Obama expects his economic stimulus, the American Recovery & Reinvestment Act of 2009, to affect the lives of many Americans. I, for one, will be attempting to capitalize on the $8,000 tax credit for first time home buyers, which I'm sure you've all heard about.

Lesser known provisions of the legislation have significant effect on the way HIPAA covered entities and business associates handle Patient Health Information (PHI). For example, under the new law, covered entities will be required to notify individuals when there has been a breach of their PHI, and business associates will be required to notify the covered entities they contract with of breaches, regardless of the terms of their contract. There are many other provisions of this new law that healthcare reimbursement professionals who exchange or utilize PHI should note. The text of the request for information created by the Department of Health and Human Services is provided here.

More information is available on this blog, and in this summary, provided by the Center for Democracy and Technology.

Monday, April 20, 2009

Red Flag Compliance Date Looms for Collection Agencies

May 1, 2009 marks the deadline for creditors, collection agencies, and anyone utilizing credit reports in deciding to extend or negotiate credit (yes, that includes you!) to comply with the FTC's Red Flag Rules. The regulations are intended to minimize the risk of identity theft, and they have far-reaching implications. The web is full of information on these wide-sweeping rules, including this from the FTC, and even a rap song from a company offering compliance-testing software (video below courtesy of youtube).

If you don't consider yourself a creditor, and as a result you think this rule might not apply to you, think again. Maybe it's because I'm a lawyer and I have mouths to feed, but my advice would be to trust only credible sources, and if there's any doubt as to whether and how this rule might apply to you, seek the advice of counsel. This information is thorough and well organized. And this is a good sample compliance policy. See our website, for more on this rule in the coming days.


Welcome to the Florida Collection Law Blog. Here you will find a discussion of issues relevant to collection agencies, creditors, and debt collection attorneys practicing in commercial, consumer, and medical collections in the State of Florida. We hope you find this site useful, and we welcome your comments. Enjoy.