Lawyers at Amador Kelly have extensive experience collecting against health plans on behalf of various healthcare providers, both contracted and non-contracted. Leveraging off his vast experience in the healthcare field, including as a chief counsel and a general counsel of large managed care companies, Mr. Amador has lectured on this complex topic.
The collection process often involves a breach of contract dispute resulting in a healthcare arbitration. Through healthcare mediation we have routinely been successful in resolving the disputes to our clients’ satisfaction.
Our lawyers have also been successful collecting healthcare receivables using ERISA assignment of benefits for non-contracted and out-of-network providers. In California and other States healthcare providers can sue to recover their claims as if they were the insured under an employment benefit plan. ERISA does not apply to individual, religious or government sponsored health plans. These disputes often involve fighting over what the appropriate “usual, customary and reasonable” amount for the services should be, as interpreted by the health plan document.
In California, regulation, Title 28 1300.71, is helpful in providing guidance to what constitutes proper payment for out of network or non-contracted providers for “reasonable and customary” disputes.