REIMBURSEMENT DISPUTES & INSURANCE ISSUES

Physician practices and other health care enterprises raise complex insurance issues. These include:

• Billing Issues
• Coding (Proper Coding, Miscoding, and Upcoding)
• Medical Fraud & Abuse
• Medicare Opt-Out
  • Advance Beneficiary Notice (ABN)
  • Medicare Opt-Out Affidavit
  • Medicare Private Contract
• Professional Liability Insurance Coverage (especially for CAM or integrative medicine)
• Reimbursement Disputes With Insurers

For example, many physicians are unsure whether to opt out of Medicare or simply not participate; unfortunately, many get snagged in needless fraud and abuse investigations simply because they are unaware of the default provisions of the Medicare rules.

Similarly, doctors using alternative therapies in integrative medicine clinics have to be careful to bill and code correctly. Incorrect billing and coding with respect to telemedicine visits can also raise regulatory red flags. Sometimes insurers can flag reimbursement submissions as not medically necessary or for “experimental” therapies and thus raise medical liability or board disciplinary issues for providers.

Healthcare providers in emerging areas of medicine must beware of hidden pitfalls, such as criminal liability for medical fraud, which can ensue from mistakes in billing and coding, including such errors as bundling charges and miscoding. Sometimes the kind of lengthy office visit that is used for an integrative medicine consult will not fit the typical E&M code.

As well, HIPAA compliance and issues of patient privacy and confidentiality require careful attention within the health care practice environment.

Many of our health care clients are concerned with obtaining the best professional liability insurance coverage. This can include not only integrative medicine and holistic doctors, but also yoga teachers and other mind-body specialists. We regularly advise clients on how to ask the right questions of their professional liability insurers regarding whether malpractice liability coverage is adequate for their needs.

Our health care attorneys can review billing and coding, plan participation, and Medicare/Medicaid issues, and otherwise advise medical and wellness practices concerning insurance legal issues.