Look Out Dermatologists, Here They Come

In a New York Times article published on January 19, 2014, the authors portray specialists, such as dermatologists, as receiving soaring income while primary care physicians are suffering financially. While there are some valid points in the piece, the health insurance and health plan payor industry is likely to look at this article through their green ($) colored glasses.

The scheme of the health insurance and health plan payors of seeking “recoupment” of funds that they previously paid is accelerating throughout the country. Essentially, these payors process claims administratively and thereafter engage in number crunching efforts to determine what they believe should not have been paid. And then they begin the process of “audit and recoupment”.

The law, however, requires these payors to do their job in the first instance; i.e., if they have questions regarding the payability or amount of any claim, they must do their homework and ask any questions within the time constraints of the ERISA claims regulations.

The payors, however, refuse to follow the proper procedures and engage in an end-run around the law. This results in large (sometimes millions of dollars) recoupment demands, wreaking havoc upon the patients and doctors who received payment and thought that the claims were well behind them, only to be shocked later at the audit and recoupment process.

While some medical charges can be unfounded, the time for the health insurance industry to raise those questions is in the proper and lawful time frame. ERISA does not permit these belated attacks upon medical providers.

Based upon the New York Times article referenced above: Dermatologists beware.

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