Legal Disputes and Contracts Regarding the Complex System of Healthcare Insurance Reimbursement
Incorrect coding leveling, improper CPT codes, RVUs, and incorrect assessments of medical-decision making complexity can result in serious reimbursement deficiencies. It is important that healthcare providers obtain proper true-ups from managed services companies, participating care centers and other entities involved in patient care.
Health Law – Lawsuits, administrative proceedings, arbitrations and mediations involving improper coding are on the rise. Our firm advises healthcare providers navigating their way through the complex system of healthcare insurance reimbursement.
Legal disputes relating to coding for maximum reimbursement are on the rise. This is due in part to the unbelievable complexity of the requirements of the Centers for Medicare & Medicaid Services (CMS) and third-party payors that often take their lead from CMS. Unfortunately, those requirements are sometimes interpreted (or more to the point, misinterpreted) by private equity investment groups and nonprofit healthcare systems that put in place managed services organizations with a deficient internal billing infrastructure. Likewise, the same problem can arise with practices that use their own healthcare management company or that internally manage their healthcare practices.
The legal issues this raises generally center on a few key points, such as for example,
- the initial negotiation before “putting pen to paper,” in which a healthcare provider’s practice is purchased based upon historical data relating to insurance reimbursement claims, with the assumption that everything will remain the same under the new regime,
- the contract of sale that provides for a complex calculation of such items as quarterly true-ups, attribution of ancillary revenue and expenses, superbills, and code leveling, all of which are oblique and subject to discretionary interpretation,
- the initial attempt to resolve the disputes over what the healthcare professional believes is the appropriate coding, pace of submission, and level of commitment to the administrative appeal process when reimbursement is rejected, and
- the resulting lawsuit or arbitration when the parties cannot resolve the dispute.
But there is an 800-pound gorilla in the room that needs to also be acknowledged: the third-party payer or government agency providing reimbursement can create a dispute where none needs to exist. Put another way, the healthcare provider and the persons or entities submitting applications for insurance reimbursement on their behalf can be doing everything right and still end up with the claim being rejected for all sorts of reasons.
The Nissenbaum Law Group is here to help. The firm welcomes inquiries relating to healthcare entity contracts with providers, disputes over the practices undertaken in regard to those contracts, ethical legal issues in medical billing and coding, and net deductions from the revenue attributable to the healthcare provider.
The firm offers its clients representation in both healthcare transactional and commercial litigation matters. That is particularly important in regard to the business aspect of the private practice of medicine within a nonprofit or private equity framework.
Mr. Nissenbaum has provided seminars and has been published in New Jersey Lawyer Magazine on the topic of healthcare law. The firm has provided legal advice and representation to a variety of healthcare professionals in everything from contractual buy-outs to commercial litigation matters. The healthcare clients Mr. Nissenbaum has participated in representing run the gamut from physicians and physician groups to psychotherapy practices, from HMOs and IPAs to hospitals.
The firm’s healthcare insurance coding practice includes the following:
- The rights of healthcare providers in regard to participating care centers that employ them,
- The propriety of quarterly true-ups and deficit account calculations
- Ancillary expenses and adjusted practice amounts
- Superbills relating to proper input of CPT codes in relation to the respective RVU that may apply
- The propriety of E/M codes (evaluation and management) and code leveling in that regard
The Nissenbaum Law Group’s Health Law Legal Practice
The Nissenbaum Law Group encourages potential healthcare clients in Pennsylvania, Texas, New York, and New Jersey to contact it regarding legal issues that may relate to contracts and/or disputes involving complex reimbursement issues.
Publications & Presentations
- 3/1/18 Interview of Mr. Nissenbaum, Systematic, “The Psychodynamics of Lawyering with Gary Nissenbaum”
- The Increasing Pace of Digital Change: Why Does Our Culture Always Seem so Blindsided?, Huffingtonpost.com, August 4, 2016
- Presented Seminar, Top 10 Legal Issues Confronting Nonprofits, State Council of New Jersey Junior League’s Get On Board Conference, April 2017
- Awarded (Nissenbaum Law Group, LLC), Law Firm/Corporate Legal Department Pro Bono Award for Small Law Firms, New Jersey State Bar Association, 2019
- Facilitator, 2003 Mediation Training, Superior Court of New Jersey, Union County
- Panelist, 1996 Annual Health Law Symposium
- Lecturer, Managed Care Provider Contracts, New Jersey Institute for Continuing Legal Education, 1996
- Seminar, Health Care: Duty of Confidentiality to AIDS Patients, New Jersey Bar Association Annual Convention; Garden State Bar Association Annual Convention, 1989
- Presented Seminar, Current Legal Issues Relating to Health Care, Graduate Studies Program in Health Advocacy, Sarah Lawrence College, 1988
Awards & Recognition
- Awarded (Nissenbaum Law Group, LLC), Law Firm/Corporate Legal Department Pro Bono Award for Small Law Firms, New Jersey State Bar Association, 2019
Looking for advice?
We're here to help.
Contact the Nissenbaum Law Group to schedule an appointment at 908-686-8000 or feel free to use the following form to e-mail us. Please include as much information as you can to ensure that we are able to handle your request as quickly as possible.
Looking for advice?
We're here to help.
Contact the Nissenbaum Law Group to schedule an appointment at 908-686-8000 or feel free to use the following form to e-mail us. Please include as much information as you can to ensure that we are able to handle your request as quickly as possible.
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