FEATURE
surgery center does not mean it is the right law firm to handle a dis- pute with an insurer, particularly if the law firm lacks past experience representing providers in managed care disputes.
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Any lawyer handling a provider/ insurer reimbursement dispute should have a solid grasp of the many types of payers out there, such as employer-sponsored health plans, individually insured poli- cies, Medicare Advantage plans, Federal Employees Health Benefits plans, health maintenance orga- nizations and Medicaid managed care plans.
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An ASC’s counsel should be well versed in the nuances of state in- surance law, the federal Employee Retirement Income Security Act (ERISA), and other laws that gov-
Several major health insurers have been aggressively using their special investigation units to institute post-payment audits targeting out-of-network providers.”
—David Greenberg, Arent Fox LLP
ern the relationship between provid- ers and insurers/plans. They must also understand the administrative appeal process.
Good legal counsel also should be able to tell you when you have no legal claims against an insurer who seemingly underpaid you. The odds are good that ASCs will continue to succeed while out of net- work. However, it will take increas- ing sophistication and diligence by ASCs to combat insurers, third-party
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administrators and plans intent on reducing reimbursement to out-of- network providers.
David S. Greenberg is a health care attorney with Arent Fox LLP in Washing- ton, DC. Contact Greenberg
at
greenberg.david@arentfox.com.
The advice and opinions expressed in this article are those of the author and do not represent offi- cial Ambulatory Surgery Center Association policy or opinion.
2012 WINTER CODING SEMINAR :
LAS VEGAS DEC 10-11 W ynn Las V e g as Hot el
• Receive CMS updates and a summation of the final rule as it pertains to reimbursements for ASCs.
• Learn everything you need to know about the CPT 2013 changes, rationales and applications.
• Obtain valuable coding tips to ensure accurate coding and reimbursements for the more commonly performed ASC procedures in specialties including orthopedics, podiatry, pain management/spine, urology, gastroenterology, general surgery and ophthalmology.
Learn more at
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10 ASC FOCUS NOVEMBER/DECEMBER 2012
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