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NON-PAR FACILITY UNDERPAYMENTS

NON-PAR FACILITY UNDERPAYMENTS. Kendall Healthcare Group, Ltd. v. Neighborhood Health Partnership, Inc .

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NON-PAR FACILITY UNDERPAYMENTS

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  1. NON-PAR FACILITY UNDERPAYMENTS Kendall Healthcare Group, Ltd. v. Neighborhood Health Partnership, Inc. Issue(s) in Dispute:Aggregate claims for patients treated in the E.R. and subsequently admitted to this HCA facility. NHP applied percentage of Medicare allowable as their reasonable and customary. This firm identified in excess of two million dollars in underpayments. Jorge M. Abril, P.A.’s Legal Posture:Initial settlement discussions proved fruitless, Jorge M. Abril, P.A. filed suit in the 11th Judicial Circuit Court of Florida. Case removed to U.S. District Court. Litigation efforts immediately promoted high level negotiations between NHP and HCA. Resolution: Favorable resolution of underpaid claims for Kendall Medical Center and all similarly situated HCA facilities.

  2. HMO DENIALS: CONTRACTED PROVIDER Mercy Hospital, Inc. v. United Healthcare of Florida, Inc. • Issue(s) in dispute: Long standing (five years) denial and underpayment disputes arising under managed care agreement between the parties. Attempts to mediate and negotiate settlements proved fruitless. Eventually negotiations broke off and suit filed. • Jorge M. Abril, P.A.’s Legal Posture:The firm brought suit for breach of contract and numerous other theories of recovery including violation of the Federal and Florida R.I.C.O., Florida civil theft, etc. United failed, in their bid, to impose arbitration clause. • Resolution: Aggressive litigation strategy forced favorable settlement, on behalf of Mercy Hospital, while preserving the relationship between the parties, resulting in new contract . .

  3. HMO DENIALS: UNTIMELY CLAIM SUBMISSION Cedars Medical Center v. Health Partners of Philadelphia • Issue(s) in dispute: Unilateral failure, on the part of the health plan, to process claim for unreasonable period of time (eight months from date of service). Claim denied for untimely submission. • Jorge M. Abril, P.A.’s Legal Posture: Filed legal action claiming bad faith for unwarranted denial of the claim. • Resolution: Immediate payment for full amount of HMO’s liability.

  4. NON-CONTRACTED CARRIER: ARBITRARY APPLICATION OF DRG/PER DIEM MEDICARE RATES Palm Springs General Hospital v. United Healthcare of Florida, Inc. • Issue(s) in dispute: HMO routinely underpaid facility by applying lowest of DRG payment rate or Non-DRG Medicare per diem rate. Clear violation of federal Medicare reimbursement statutes • Jorge M. Abril, P.A.’s Legal Posture:The firm requested an advisory opinion substantiating its position. • Resolution: Upon receipt of favorable advisory opinion, managed care plan conducted audit and adjusted for proper reimbursement.

  5. HOSPITAL LIEN IMPAIRMENT HealthSouth Doctors’ Hospital v. D.A.C & L.C. • Issue(s) in dispute: Personal injury attorney refused to recognize hospital lien on the basis that the injuries sustained were a result of a violent crime. • Jorge M. Abril, P.A.’s Legal Posture:The firm filed suit against the patient and guarantor seeking enforcement of hospital’s lien. • Resolution: The firm obtained significant partial payment from the State of Florida’s Crime Victims Compensation Fund and then proceeded to secure further remuneration from award of damages in tort action against person(s) responsible for the injuries.

  6. RETROACTIVE TERMINATION OF COVERAGE FOR LATE PAYMENT OF PREMIUMS Pan American Hospital, Inc. v. Y.S.A. v. United Healthcare of Florida • Issue(s) in dispute: Despite accepting receipt of late payments, HMO rescinded member’s policy and denied claims related to this admission. • Jorge M. Abril, P.A.’s Legal Posture:The firm filed suit directly against the patient, whom subsequently brought third party action against the HMO on estoppel theory. • Resolution: The case was tried before the Court. Award of damages in favor of provider and member. United Healthcare ordered to pay its full responsibility to the facility, plus interest and attorneys’ fees.

  7. CATASTROPHIC CLAIM CARVE-OUTS Mount Sinai Medical Center, Inc. v. Vista Health Plans, Inc., as successor to Foundation Health • Issue(s) in dispute: Hospital identified a disturbing pattern of underpayments by the health plan on high dollar catastrophic claims. • Jorge M. Abril, P.A.’s Legal Posture:The firm brought suit in circuit court under breach of contract and other legal remedies. • Resolution: The HMO has asserted an aggressive defense to the issues raised in the pleadings. Both sides are currently exploring settlement options. To date, no resolution has been obtained and the case is proceeding to trial in late 2006.

  8. UNDERPAYMENTS/DENIALSNON-CONTRACTED ANCILLARY PROVIDER West Dade Anesthesia Associates v. Total Health Choice, Inc. • Issue(s) in dispute: HMO unilaterally underpaid and denied dozens of claims by applying an incorrect reimbursement code, in direct violation of the parties’ Provider Service Agreement. • Jorge M. Abril, P.A.’s Legal Posture:A multi-count complaint was filed, in Miami-Dade county Circuit Court, under numerous theories of recovery, including breach of contract. • Resolution: After several months of contentious litigation, the parties came together to negotiate global settlement, including the execution of a revised contract with increased provider payment rates. The new contract served as an incentive for an amicable settlement of all issues.

  9. CONTRACT INTERPRETATION DISPUTE American Medical Response (AMR) v. CarePlus Health Plans, Inc. • Issue(s) in dispute: The health plan issued a sharp increase in provider payments due to its inability to control utilization after parties moved to fee for service compensation. Health plan unilaterally withheld significant payments to the provider. • Jorge M. Abril, P.A.’s Legal Posture:In order to uphold the long-standing relationship between the parties, the firm refrained from filing suit and, instead, engaged in high level negotiations with health plan executives. • Resolution: The parties executed a global settlement and executed a revised contract premised on the health plan exercising greater control over utilization, while still compensating the provider at competitive and profitable rates.

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