American Medical News

The American Medical Association recently estimated that an additional $43 billion could have been obtained by doctors since the year 2010 if commercial payors had paid health plan claims correctly. The AMA’s publication, American Medical News, interviewed Richard to see how how doctors and hospitals could obtain those funds, that are essentially “left on the table”.

While claim coders and other practitioners in the health care claims and reimbursement field focus upon a doctor’s compliance with rules that insurers and payors “set”, Quadrino Law Group views the claims process, as it currently exists, as upside down. In turning it right side up, the focus, as Richard Quadrino teaches, is to evaluate the legality of the plan’s conduct and to seize upon unlawful tactics and claims conduct as a means to obtain payment.

When we write that payors, such as health plan administrators and health insurance companies “set” rules, we are referring to essentially their entire claim regimens, that are often created out of whole cloth, without a legal foundation. These “policies” or “guidelines” are often unlawful and cannot be imposed upon medical providers as guiding rules for the payment of health insurance claims.

The essence of this problem has been explained, in a similar context, by the United States Supreme Court. The fundamental question is: can a health insurance company can set up binding rules of the road that are (1) not contained in a group health plan’s terms, and (2) not allowed by the governing ERISA federal claims regulations?

Richard says no. They cannot. And he’s backed up a tiny court of only 9 people, sitting in a building on a quiet sidestreet behind the nation’s capitol: The United States Supreme Court.

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