Last week, SAC successfully recovered nearly $1M in arbitration against a major commercial payer which involved two of the most difficult reimbursement issues providers face:

• Access to payers’ contracts
• Disallowed charges

As you know, many large commercial payers allow other payers to access the rates they negotiate with providers. These often take the form of Administrative Services Only (ASO) arrangements where the contracting payer is only the administrator and pricer of the claims. This presents difficulties in seeking reimbursement as the contracting payer includes provisions in the contract absolving them of any financial responsibility if the accessing payer fails to pay.

However, despite the contractual language indicating the payer was not financially responsible, we were able to prevail based on a breach of the responsibility for accurate pricing.

SAC also prevailed on the issue of disallowed charges, despite the Operations Manual of the payer specifically listing the revenue codes upon which reimbursement was sought being listed as not billable under the circumstances presented by the claims.

Typically, arbitrators will uphold disallowed charges denials if the contract or the operations manual is clear on what charges are disallowed. Based on the specific definitions of the services and products listed in the Manual, SAC was able to convince the arbitrator the charges should not be disallowed.

Hospitals provide an invaluable service to our communities and we are committed to identifying those opportunities where improper denials should be overturned so that our hospitals can be appropriately reimbursed.

Please don’t hesitate to contact us for any advice, guidance, or recovery/collection help you need.