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Showing 4 posts from February 2019.

Recently, many of our clients have found that more and more of their in-network, contracted claims which they have billed to the various payors are being denied, in whole or in part, for an alleged lack of medical necessity. This article provides some considerations to be made when dealing with payors who have denied claims based on medical necessity grounds.

Examine Your Contract

                Definition of Medical Necessity

Providers should examine their contracts with the payor at issue. First, determine how the terms “Medical Necessity” or “Medically Necessary Services” (or the equivalent) have been defined in your contract. Ensuring that the services in question comply with that definition will be critical to succeeding in any challenge to the payor’s denial of the claim. Should any challenge of the payor’s denial result in litigation or arbitration, your expert witness will also need to become very familiar with the definition included in your contract and be able to support that the services provided do meet the definition provided. Read More ›

Hooper, Lundy & Bookman congratulates our 2019 Southern California Super Lawyers. Super Lawyers ranks those who have attained a high degree of peer recognition and professional achievement, and the selection process includes independent research, peer nominations and peer evaluations.  Hooper, Lundy & Bookman has more ranked lawyers in health care than any other firm in Southern California. 

  • Lloyd Bookman
  • David Hatch
  • John Hellow
  • David Henninger
  • Patric Hooper
  • Linda Kollar
  • Robert Lundy
  • Charles Oppenheim
  • Devin Senelick   
  • Brad Tully

On February 4, 2019, the California Court of Appeal affirmed a judgment awarding plaintiff, Dr. Kenneth Economy, substantial damages for his suspension and subsequent termination of his staff privileges at defendant Sutter East Bay Hospitals. The Court of Appeal held that, because Dr. Economy’s termination, even though done under the provisions of an exclusive contract, was based on “medical disciplinary cause or reason,” he was entitled to prior notice and a hearing in accordance with Business and Professions Code section 809 et seq. This decision flies in the face of the underlying premise for exclusive contracts: the ability for a hospital to enter into a contractual arrangement that allows it to set superior metrics in exchange for exclusive rights to provide services. Clinical issues have long been mandated to be within the purview of the medical staff but exclusive contracting gives hospitals the ability to contract for higher standards of quality of care. The severity of the Economy decision calls into question the accepted approach to exclusive contracts. Read More ›

Washington, DC -- Health care executives from across the country believe that extensive changes are coming to U.S. health care in the coming years—maybe even the next two. That’s according to a new survey by national law firm Hooper, Lundy & Bookman, P.C., released in concert with its inaugural National Symposium on Health Law and Policy.

The 2019 Health Law & Policy Report was completed by 222 health care executives from across the United States. Respondent titles ranged from Chief Executive Officer to Manager, and respondents represented a wide variety of organizations. Read More ›

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