While most in Jacksonville likely value the assistance their insurers offer, they also may understand that insurance companies are businesses, and that businesses typically do not remain in operation by giving away money. Thus, the idea that insurers may constantly be on the lookout for loopholes that allow them to deny or reduce coverage may be more of a fact than a notion. Yet it should be remembered that despite their efforts to save money, insurers are obligated to provide coverage and reimbursement according to the promises made in the contracts they have with their clients. 

A recent ruling in a reimbursement dispute in Texas reaffirms this fact. A local area hospital had sued one of its contracted insurance partners for denying more than $10 million in patient claims. The insurer cited an outdated capitation agreement that it had with a clinic only loosely affiliated with the hospital as the basis for the denials. This reason was given despite the hospital having a current contract with the company that contained different reimbursement provisions (which included payment at 100 percent of the Medicare allowed amount on claims). The judge hearing the case agreed with the hospital’s argument, and went even further in saying that insurers shorting providers their payments could potentially put patients at risk. 

Healthcare providers expend a great deal of resources when providing services. Their ability to continue to meet the needs of their patient populations depends largely on what they are paid by insurers. Therefore, patients and providers alike may have a vested interest in ensuring that services are paid for as promised by their insurers. Those needing to have such promises enforced may want to enlist the services of a skilled and experienced attorney. 

Source: NB Herard “Mahendru P.C. Wins Insurance Dispute for Houston-area Hospital” Brunner, Carrie, Dec. 14, 2017