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Fetured Job Of the Day
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Patent Attorney with 1-4 years of engineering experience

Boulder office seeks patent attorney having 1-4 years of experience. T...
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Date Posted: Oct 20, 2017

Employer:   BCG Attorney Search

Salary: Not Specified


Los Angeles
1875 Century Park East, Suite 1600
Los Angeles, California - 90067-2517



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Staff Size : 39
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Law Firm News


Dear Clients and Friends:

Many of our hospital clients are experiencing specific types of payment problems with PacifiCare that we wish to bring to your attention. In light of the issues described below, we encourage you to review your accounts receivable and contracts.

Medical Bill Review
PacifiCare has recently instituted a program – called Medical Bill Review -- to disallow and deny certain charges in order to reduce the claim below the stop loss threshold or to reduce the stop loss payment. Rather than amend its contracts with providers, PacifiCare has unilaterally changed the manner in which claims are reimbursed under its hospital contracts. Like other health plans, PacifiCare is improperly attempting to apply Medicare guidelines to deny these charges. We have been successful in having these charges paid in numerous arbitrations.

It has come to our attention that PacifiCare is denying payment for certain types of implants by improperly applying a narrow definition as to what constitutes an implant. Many hospital contracts do not define what items constitute an implant. PacifiCare's definition of what constitutes an implant is much narrower than the UB-92 Manual definition of an implant. We believe it is improper for PacifiCare to unilaterally adopt a narrow definition of implants without defining that term in the contract. Our firm has been successful in litigating this issue in a number of arbitrations.

Most Favored Nation Provisions
In many new contracts, PacifiCare and United Healthcare ("UHC") are requiring hospitals to ensure that the rates PacifiCare/UHC negotiates with the hospital are as low as the lowest rates in the hospital's contracts with other health plans. PacifiCare/UHC is also insisting that the hospital agree that a third party auditor review all of the hospital's contracts and claims to ensure that PacifiCare/UHC is receiving the lowest rates. We believe that this practice is improper for a number of reasons:

First, such a practice may require the hospital to breach the confidentiality provisions of its contracts with other health plans. PacifiCare certainly would not want its contract rates to be disclosed to other health plans.
Second, there may be HIPAA issues if PacifiCare's auditor were to review claims relating to other health plans.
Third, the practice may be anti-competitive or otherwise constitute unfair business practices. PacifiCare certainly would not disclose the rates it pays other hospitals, or agree to a provision that states that it will pay the hospital the highest rate it pays other hospitals in the area.
Fourth, the rates that hospitals negotiate with different health plans depend in large part on volume and utilization of services.

Primary Practice Areas

Real Estate,Healthcare and Hospital Law General Business Matters, Joint Ventures, Managed Care, Fraud and Abuse, Health Care Financing, Third-Party Payment Programs, Medical Staff, Licensing and Certification Issues, Administrative Law and Regulatory Litigation, Civil Litigation, Long-Term Care.

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