We provide a turn-key process to appeal out-of-network claims. Claims that have been processed but paid less than your billed charges are eligible for a legal appeal under federal and state law. MedCapp uses a legal algorithm and claim specialists to appeal claims directly to the payor and/or plan administrators using proven strategies.
Contingency pricing is available with a no-risk guarantee to collect more on claims that would otherwise not result in any additional payment. MedCapp ensures your appeal (i) collects more, (ii) sets the legal record straight, and (iii) exhausts the administrative process.
Federal (ERISA) & State Law
Based Appeal Process
MedCapp appeals claims based on applicable federal and/or state law. Any claim that pays less than billed charges is considered an adverse benefit determination and is eligible for an appeal for ERISA-governed plans. The first dollar paid in a provider's revenue cycle management is the easiest to collect, but the last dollar is the hardest. By utilizing the tools the law gives providers to appeal health claims, MedCapp makes collecting that last dollar just as easy as the first.
In addition to the typical denial management cycles that all providers must address with payors, out-of-network providers have the additional burden of not having a prenegotiated rate that it is entitled to be reimbursed; instead, providers must rely on the payors to follow the terms of their plans on the level of reimbursement. Unfortunately, many payors fail to do so. MedCapp holds payors to the terms of their plans and challenges their reimbursement methodology with the objective of collecting more.
ERISA (Employee Retirement Income Security Act) governs self-funded insurance plans, with few exceptions. ERISA provides for a very specific appeals process that MedCapp utilizes for many of its claims recovery processes. MedCapp implements a robust ERISA-based appeals process with three objectives: (i) collect more, (ii) exhaust the administrative appeals process, and (iii) establish a clear administraive record for further judicial review.
A very common tactic of cost containment by payors against out-of-network providers is to find fraud (especially when there may not be fraud) in order to justify low or non payment. Just remember, these payors get dinged every year for what a small provider would go to jail for.
Read more here.
Court has ruled in Beverly Oaks Physicians Surgical Ctr., LLC v. Blue Cross & Blue Shield of Illinois, 983 F.3d 435, 442 that there facts sufficient to suggest that Blue Cross waived the anti-assignment provision by failing to assert it sooner.
Plan will soon be required to disclose historical payments to, and billed charges from, out-of-network providers & negotiated rates for all covered items and services between the plan and in-network providers. This is a game changer for out-of-network providers!
CARES Act generally requires plans and issuers providing coverage for the items and services described in section 6001(a) of the FFCRA to reimburse any provider of COVID-19 diagnostic testing an amount that equals the negotiated rate or, if the plan or issuer does not have a negotiated rate with the provider, the cash price for such service that is listed by the provider on its public website.
The deadline under the plan by which participants may file a benefit claim (under the terms of the plan) and the 180-day (for group health plans) and 60-day (for other welfare benefit plans) deadlines for appealing an adverse benefit determination. This means that, as of March 1, 2020 and through the end of the outbreak period, there are no deadlines to file claims or appeals.